Provider Demographics
NPI:1568795219
Name:YOUNG, GENIA LETICIA
Entity Type:Individual
Prefix:
First Name:GENIA
Middle Name:LETICIA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 SAWTELLE BLVD STE 610
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7013
Mailing Address - Country:US
Mailing Address - Phone:323-457-3037
Mailing Address - Fax:
Practice Address - Street 1:1849 SAWTELLE BLVD STE 610
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7013
Practice Address - Country:US
Practice Address - Phone:323-457-3037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91339106H00000X
14240221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist