Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 20040134A | IN |
Y | 103TC0700X | Clinical Psychologist | 20040134A | IN |
N | 103G00000X | Clinical Psychologist | 20040134A | IN |
N | 103TC0700X | Clinical Psychologist | 20040134A | IN |
N | 103TR0400X | Rehabilitation Psychologist | 20040134A | IN |
NPI | 1548472863 |
---|---|
Provider Name | William Henry Youngs |
First Address | Mishawaka, IN 46545-3194 |
Second Address | Mishawaka, IN 46545-3194 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 05/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
20040134A | PSYCHOLOGY LICENSE (01) | IN |