Provider Demographics
NPI:1891707758
Name:YOUNG, MARY LOU CARMEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:CARMEN
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 1:6874 RANCHGROVE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-5307
Mailing Address - Country:US
Mailing Address - Phone:951-780-7986
Mailing Address - Fax:
Practice Address - Street 1:LOMA LINDA VA MEDICAL CTR
Practice Address - Street 2:11201 BENTON STREET
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 233931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical