Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | LP5036 | MN |
Y | 103TC0700X | Clinical Psychologist | LP5036 | MN |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | LP5036 | MN |
N | 103TF0200X | Forensic Psychologist | LP5036 | MN |
NPI | 1083927917 |
---|---|
Provider Name | Dr. Kenneth Ray Young JR. |
First Address | Minnetonka, MN 55343-4157 |
Second Address | Minnetonka, MN 55343-4157 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2010 |
Last Update Date | 04/12/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1083927917 | (05) | MN |