Basic Information
| Provider Information | |||||||||
| NPI: | 1851416812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | CLEO | ||||||||
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| Credential: | M.F.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3224 EAST YORBA LINDA BLVD. | ||||||||
| Address2: | #313 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92831 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2116 ARLINGTON AVE. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237373900 | ||||||||
| FaxNumber: | 3237373993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 06/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | MFC50290 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 106H00000X | 05 | CA | MEDICAID |