Provider Demographics
NPI:1649815119
Name:YOUNG, CLARENCE A (CDCA)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 ELM ST APT 8
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-6993
Mailing Address - Country:US
Mailing Address - Phone:513-332-7568
Mailing Address - Fax:
Practice Address - Street 1:3009 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2419
Practice Address - Country:US
Practice Address - Phone:513-872-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169409101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)