Provider Demographics
NPI:1023835923
Name:YOUNG, TYLER JONATHAN
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JONATHAN
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 1:6111 GROVE LAKE CT APT 1023
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3077
Mailing Address - Country:US
Mailing Address - Phone:919-931-8739
Mailing Address - Fax:
Practice Address - Street 1:7200 CREEDMOOR RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1711
Practice Address - Country:US
Practice Address - Phone:919-912-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health