=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629891684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMILLYA SHAMEQUA SIMONE YOUNG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5718 WESTHEIMER RD STE 1000
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77057-9903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-355-4305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15013 ALKAY ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77053-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-896-3756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 96910
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------