Provider Demographics
NPI:1932580933
Name:DEYOUNG, NATHANIEL (PHD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:DEYOUNG
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 1:1970 ROANOKE BLVD
Mailing Address - Street 2:MHSL 116B
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-251-5625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005147103TC0700X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist