Provider Demographics
NPI:1306912530
Name:YOUNG, JOHN C (LISW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LIVE OAK LN
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-7428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 WREN ST
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-1529
Practice Address - Country:US
Practice Address - Phone:803-259-5762
Practice Address - Fax:803-259-3250
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1004104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1004OtherMEDICAL LICENSE
SCSW1311Medicaid