Provider Demographics
NPI:1932210663
Name:KEVIN W YOUNG, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KEVIN W YOUNG, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-783-5262
Mailing Address - Street 1:325 N AVENUE F
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-5042
Mailing Address - Country:US
Mailing Address - Phone:337-783-5262
Mailing Address - Fax:337-783-5264
Practice Address - Street 1:325 N AVENUE F
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-5042
Practice Address - Country:US
Practice Address - Phone:337-783-5262
Practice Address - Fax:337-783-5264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09967R103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1997846Medicaid
LA5U741Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #
LAF89765Medicare UPIN
LA1997846Medicaid