Healthcare Provider Details

I. General information

NPI: 1669337366
Provider Name (Legal Business Name): MODERN YOUTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33309 1ST WAY S STE A-105
FEDERAL WAY WA
98003-6260
US

IV. Provider business mailing address

PO BOX 772
ENUMCLAW WA
98022-0772
US

V. Phone/Fax

Practice location:
  • Phone: 253-335-6013
  • Fax:
Mailing address:
  • Phone: 253-335-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: KELLY FERGUSON
Title or Position: PROVIDER/OWNER
Credential: LMHCA
Phone: 253-335-6013