Healthcare Provider Details

I. General information

NPI: 1861228629
Provider Name (Legal Business Name): YOUNG EUN SONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MINA SONG

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 S MAIN ST STE 101
CLARKSTON MI
48346-2377
US

IV. Provider business mailing address

430 W 9 MILE RD APT 210
FERNDALE MI
48220-3031
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-2970
  • Fax:
Mailing address:
  • Phone: 714-356-0433
  • 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: