Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003186818 |
---|---|
Provider Name | Edgar T. Young |
First Address | Fremont, CA 94555-3261 |
Second Address | Fremont, CA 94555-3261 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2012 |
Last Update Date | 10/01/2012 |