MEDICARE: ANTHONY DEJOHN YOUNG MA, LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	13080	TX

General Provider Information

NPI Number	:	1881216158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY DEJOHN YOUNG MA, LCDC

Provider Business Mailing Address
First Line	:	2219 GREENHOUSE RD APT 2306
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-7318
Country	:	US
Telephone Number	:	832-752-4772
Fax Number	:

Provider Business Practice Location Address
First Line	:	2219 GREENHOUSE RD APT 2306
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-7318
Country	:	US
Telephone Number	:	832-752-4772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2020
Last Update Date	:	05/10/2020

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