Provider Demographics
NPI:1942775895
Name:YOUNG, BETHANY LEA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:LEA
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 1:4249 AUTUMN CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32305-6664
Mailing Address - Country:US
Mailing Address - Phone:850-926-1900
Mailing Address - Fax:
Practice Address - Street 1:4750 CAPITAL CIR SE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-7837
Practice Address - Country:US
Practice Address - Phone:850-320-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL148931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty