Provider Demographics
NPI:1841961240
Name:YOUNG, EVAN WALLACE
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:WALLACE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 BAGBY RD
Mailing Address - Street 2:
Mailing Address - City:CRITTENDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41030-8957
Mailing Address - Country:US
Mailing Address - Phone:859-391-1344
Mailing Address - Fax:
Practice Address - Street 1:840 BAGBY RD
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-8957
Practice Address - Country:US
Practice Address - Phone:859-391-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst