Healthcare Provider Details

I. General information

NPI: 1699799098
Provider Name (Legal Business Name): YONG S SONG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD (MAILCODE: 116B), BLDG 257
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

11301 WILSHIRE BLVD (MAILCODE: 116B), BLDG 257
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 310-478-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY16860
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY16860
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY16860
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY16860
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY16860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: