Provider Demographics
NPI:1043751514
Name:SONG, YOUNG (CPED)
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14431 41ST AVE STE L6
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-1452
Mailing Address - Country:US
Mailing Address - Phone:718-359-3348
Mailing Address - Fax:718-359-0388
Practice Address - Street 1:14431 41ST AVE STE L6
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1452
Practice Address - Country:US
Practice Address - Phone:718-359-3348
Practice Address - Fax:718-359-0388
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCPED3468224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02620120Medicaid
NY5144290001Medicare NSC