Basic Information
| Provider Information | |||||||||
| NPI: | 1790182970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | ANGELINA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CAARR CERTIFICATE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNG | ||||||||
| OtherFirstName: | DENISE | ||||||||
| OtherMiddleName: | ANGELINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CAARR CERTIFICATION | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4974 EL CAJON BLVD. | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921152476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192864600 | ||||||||
| FaxNumber: | 6192860060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4974 EL CAJON BLVD. | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921152476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192864600 | ||||||||
| FaxNumber: | 6192860060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2014 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.