MEDICARE: MR. HERMAN PURNELL YOUNG LICSW-C

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	1041C0700X	Clinical Social Worker	LCSW-C 07593	MD

General Provider Information

NPI Number	:	1851606552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HERMAN PURNELL YOUNG LICSW-C

Provider Business Mailing Address
First Line	:	5803 SUPRA PL
Second Line	:
City	:	RIVERDALE
State	:	MD
Zip	:	20737-3523
Country	:	US
Telephone Number	:	301-486-0976
Fax Number	:	301-486-1901

Provider Business Practice Location Address
First Line	:	4710 PENNINGTON AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21226-1444
Country	:	US
Telephone Number	:	410-878-7030
Fax Number	:	410-800-4871

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

Provider Enumeration Date	:	08/18/2010
Last Update Date	:	08/18/2010

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