Provider Demographics
NPI:1780053686
Name:YOUNG, KATHLEEN MARIE (PHD, MPH)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PHD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-667-9402
Mailing Address - Fax:
Practice Address - Street 1:2523 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6003
Practice Address - Country:US
Practice Address - Phone:910-763-5522
Practice Address - Fax:910-763-0413
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5569103T00000X
NY0201191103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08934761Medicaid
MS08934761Medicaid