Provider Demographics
NPI:1245269117
Name:JO, MI-YEOUNG (PSYD, ABPP)
Entity type:Individual
Prefix:DR
First Name:MI-YEOUNG
Middle Name:
Last Name:JO
Suffix:
Gender:F
Credentials:PSYD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15335 MORRISON ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1585
Mailing Address - Country:US
Mailing Address - Phone:818-647-0105
Mailing Address - Fax:
Practice Address - Street 1:15335 MORRISON ST STE 205
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-647-0105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20814103TC0700X
NY014787103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVM1221Medicare ID - Type Unspecified