Healthcare Provider Details

I. General information

NPI: 1669693644
Provider Name (Legal Business Name): VICKI LJ YOUNG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 DOMINGO ST. STE 204
BERKELEY CA
94702
US

IV. Provider business mailing address

2404 SACRAMENTO ST.
BERKELEY CA
94702
US

V. Phone/Fax

Practice location:
  • Phone: 510-704-9467
  • Fax:
Mailing address:
  • Phone: 510-704-9467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 11211
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: