Provider Demographics
NPI:1104103886
Name:YOUNG, TIMOTHY DEWAYNE
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DEWAYNE
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 1:1317 E. WALLACE ST.
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-6412
Mailing Address - Country:US
Mailing Address - Phone:405-243-3798
Mailing Address - Fax:
Practice Address - Street 1:1317 E WALLACE ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6412
Practice Address - Country:US
Practice Address - Phone:405-243-3798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst