Healthcare Provider Details

I. General information

NPI: 1366491086
Provider Name (Legal Business Name): THOMAS F YOUNG PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 CROMWELL AVE
LOS ANGELES CA
90027-1354
US

IV. Provider business mailing address

11901 SANTA MONICA BLVD STE 504
LOS ANGELES CA
90025-2767
US

V. Phone/Fax

Practice location:
  • Phone: 323-854-7057
  • Fax:
Mailing address:
  • Phone: 323-512-7959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY18246
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18246
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: