Healthcare Provider Details

I. General information

NPI: 1356261788
Provider Name (Legal Business Name): YOUNG HEADWATERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W DRYDEN ST APT 209
GLENDALE CA
91202-3739
US

IV. Provider business mailing address

213 N GLENDALE AVE # 1024
GLENDALE CA
91206-4455
US

V. Phone/Fax

Practice location:
  • Phone: 818-208-1774
  • Fax:
Mailing address:
  • Phone: 818-208-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ANN M YOUNG
Title or Position: OWNER
Credential:
Phone: 818-208-1774