Provider Demographics
NPI:1508685397
Name:YOUNG, CHARLES A JR (MSW, LSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:YOUNG
Suffix:JR
Gender:M
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 SANGAMON DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4756
Mailing Address - Country:US
Mailing Address - Phone:217-418-1436
Mailing Address - Fax:
Practice Address - Street 1:1806 WOODFIELD DR STE 105
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-9505
Practice Address - Country:US
Practice Address - Phone:217-766-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.111357104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker