Provider Demographics
NPI:1407136146
Name:YOUNG, FANIKE-KIARA OLUGBALA (LCSW)
Entity Type:Individual
Prefix:
First Name:FANIKE-KIARA
Middle Name:OLUGBALA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2283 NOTTLEY WALK
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-8610
Mailing Address - Country:US
Mailing Address - Phone:770-502-5593
Mailing Address - Fax:
Practice Address - Street 1:157 FORSYTH ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3634
Practice Address - Country:US
Practice Address - Phone:770-502-5593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0046941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical