Provider Demographics
NPI:1366105330
Name:YOUNG, JAMES ROBERT (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6317 GREENWAY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-4693
Mailing Address - Country:US
Mailing Address - Phone:817-308-9487
Mailing Address - Fax:
Practice Address - Street 1:6317 GREENWAY RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-4693
Practice Address - Country:US
Practice Address - Phone:817-308-9487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23013103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical