Healthcare Provider Details

I. General information

NPI: 1700292158
Provider Name (Legal Business Name): RAY YOUNG LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6153 W OLIVE AVE
GLENDALE AZ
85302-4564
US

IV. Provider business mailing address

3003 N CENTRAL AVE SUITE 200
PHOENIX AZ
85012-2902
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 623-937-2589
Mailing address:
  • Phone: 602-302-7715
  • Fax: 602-302-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-15995
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: