Provider Demographics
NPI:1568710325
Name:YOUNG, MATTHEW RICHARD (LSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13433 DETROIT AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4616
Mailing Address - Country:US
Mailing Address - Phone:206-371-9984
Mailing Address - Fax:
Practice Address - Street 1:13433 DETROIT AVE APT 102
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4616
Practice Address - Country:US
Practice Address - Phone:206-371-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1601171104100000X
IL150013790104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker