Provider Demographics
NPI:1518167881
Name:YOUNG, ROGER LEE (MS,LCSW,LPC,CSAC)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:LEE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MS,LCSW,LPC,CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 SUNNYSIDE CRES
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3536
Mailing Address - Country:US
Mailing Address - Phone:608-244-8802
Mailing Address - Fax:
Practice Address - Street 1:4105 SUNNYSIDE CRES
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3536
Practice Address - Country:US
Practice Address - Phone:608-244-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI451-132101YA0400X
WI540-125101YP2500X
WI1300-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41001200Medicaid