Provider Demographics
NPI:1578065488
Name:YOUNG, MISTY GABRIELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:GABRIELLE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9417 MAGNOLIA RIDGE DR UNIT 103
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-6785
Mailing Address - Country:US
Mailing Address - Phone:502-259-8935
Mailing Address - Fax:
Practice Address - Street 1:10300 BROOKRIDGE VILLAGE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4474
Practice Address - Country:US
Practice Address - Phone:502-259-8935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2529941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical