Healthcare Provider Details

I. General information

NPI: 1073913414
Provider Name (Legal Business Name): KELLY YOUNGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 39TH ST
RICHMOND CA
94805-2212
US

IV. Provider business mailing address

805 KINKEAD WAY APT 104
ALBANY CA
94706-2636
US

V. Phone/Fax

Practice location:
  • Phone: 510-412-5930
  • Fax:
Mailing address:
  • Phone: 650-465-2977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: