Healthcare Provider Details

I. General information

NPI: 1144755364
Provider Name (Legal Business Name): GARY YOUNG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 MITCHELL BLVD BLDG 375
LAUGHLIN AFB TX
78843-5242
US

IV. Provider business mailing address

590 MITCHELL BLVD BLDG 375
LAUGHLIN AFB TX
78843-5242
US

V. Phone/Fax

Practice location:
  • Phone: 830-298-6422
  • Fax:
Mailing address:
  • Phone: 830-298-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3716-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: