Provider Demographics
NPI:1578056214
Name:YOUNG, REGGIE III
Entity Type:Individual
Prefix:MR
First Name:REGGIE
Middle Name:
Last Name:YOUNG
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12709 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-3811
Mailing Address - Country:US
Mailing Address - Phone:704-352-3548
Mailing Address - Fax:
Practice Address - Street 1:519 W JOHN ST
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5352
Practice Address - Country:US
Practice Address - Phone:704-508-9779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC175T00000X
NCP0167261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty