Provider Demographics
NPI:1881779486
Name:YOUNG, WAYNE T (PHD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:T
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 NORTHFIELD AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1107
Mailing Address - Country:US
Mailing Address - Phone:973-325-2466
Mailing Address - Fax:973-228-0581
Practice Address - Street 1:743 NORTHFIELD AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1107
Practice Address - Country:US
Practice Address - Phone:973-325-2466
Practice Address - Fax:973-228-0581
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100122500103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
YO648692Medicare ID - Type Unspecified