Provider Demographics
NPI:1083160790
Name:YOUNG, KIM KORY (MHTECHICIAN/LLMSW)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:KORY
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MHTECHICIAN/LLMSW
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:K
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 N JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341
Mailing Address - Country:US
Mailing Address - Phone:248-613-4098
Mailing Address - Fax:
Practice Address - Street 1:116 N JOHNSON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1330
Practice Address - Country:US
Practice Address - Phone:248-613-4098
Practice Address - Fax:248-622-4081
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-04781101YA0400X
MI175T00000X
175T00000X
MIL148347247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIL148347OtherDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF HEALTH CARE SERVICES