=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699182592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD C YOUNG LCSW INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2014
-----------------------------------------------------
Last Update Date | 07/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 412 S CLAY AVE SUITE 200
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-5860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-550-2251
-----------------------------------------------------
Fax | 314-822-9696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 S CLAY AVE SUITE 200
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-5860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-550-2251
-----------------------------------------------------
Fax | 314-822-9696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RICHARD CHARLES YOUNG
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 314-550-2251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 2006022838
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------