Provider Demographics
NPI:1992991079
Name:YOUNG, NICOLE (PSYD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:FENTIN-THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:11650 IBERIA PLACE
Mailing Address - Street 2:#130
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:
Practice Address - Street 1:11650 IBERIA PL STE 130
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2431
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN