Provider Demographics
NPI:1699966507
Name:YOUNG, DWIGHT (LCP)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530
Mailing Address - Country:US
Mailing Address - Phone:620-792-2544
Mailing Address - Fax:620-792-7052
Practice Address - Street 1:5815 BROADWAY
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530
Practice Address - Country:US
Practice Address - Phone:620-792-2544
Practice Address - Fax:620-792-7052
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS208103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy