Provider Demographics
NPI:1144300823
Name:YOUNG, KRISTIN IRENE (MSSW LCSW)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:IRENE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MSSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 ALROSE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5802
Mailing Address - Country:US
Mailing Address - Phone:901-481-1750
Mailing Address - Fax:
Practice Address - Street 1:106 CYPRESS AVE
Practice Address - Street 2:EAST ARKANSAS YOUTH SERVICES
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364
Practice Address - Country:US
Practice Address - Phone:870-739-4219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 84031041C0700X
AR2225-C1041C0700X
TNLSW00000049781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7684118 00Medicaid