=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912483348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUNG PSYCHOLOGICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 SUNCHASE DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28306-8099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-797-3302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1830 OWEN DR STE 10-12
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-797-3302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIM YVONN YOUNG
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 910-797-3302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------