Provider Demographics
NPI:1063276285
Name:YOUNG, JAVAN EMELIO II
Entity type:Individual
Prefix:
First Name:JAVAN
Middle Name:EMELIO
Last Name:YOUNG
Suffix:II
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 1:2814 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-2659
Mailing Address - Country:US
Mailing Address - Phone:941-278-9254
Mailing Address - Fax:
Practice Address - Street 1:4940 NORTHDALE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1075
Practice Address - Country:US
Practice Address - Phone:813-485-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-303469106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-23-303469OtherRBT