Provider Demographics
NPI:1871862193
Name:YOUNG, THEODORE JR (LMSW, C-ASWCM, MPA)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:YOUNG
Suffix:JR
Gender:M
Credentials:LMSW, C-ASWCM, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 WYNDSOR DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-2210
Mailing Address - Country:US
Mailing Address - Phone:423-710-1362
Mailing Address - Fax:
Practice Address - Street 1:6098 DEBRA RD
Practice Address - Street 2:SUITE 5200
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5702
Practice Address - Country:US
Practice Address - Phone:423-893-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical