Provider Demographics
NPI:1336816149
Name:YOUNG, GLORIA
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 HILTON AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-3123
Mailing Address - Country:US
Mailing Address - Phone:626-224-8768
Mailing Address - Fax:
Practice Address - Street 1:1891 EFFIE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-1711
Practice Address - Country:US
Practice Address - Phone:818-485-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-28
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022745363LP0808X
CA95203767163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health