Provider Demographics
NPI:1831336841
Name:YOUNG, KEVIN B (LCSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 N 400 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5471
Mailing Address - Country:US
Mailing Address - Phone:208-785-3658
Mailing Address - Fax:
Practice Address - Street 1:210 E CENTER ST STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6326
Practice Address - Country:US
Practice Address - Phone:208-234-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-276081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical