=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548277239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEIL P YOUNG PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 04/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2504 CLAY ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94115-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-567-8881
-----------------------------------------------------
Fax | 415-388-3707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1212 LATTIE LN
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-388-3707
-----------------------------------------------------
Fax | 415-388-3707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY5286
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------