Provider Demographics
NPI:1356926729
Name:YOUNG, KIMBERLY DIANE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
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 1:6630 AVENIDA VALENCIA
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-5625
Mailing Address - Country:US
Mailing Address - Phone:951-784-0843
Mailing Address - Fax:
Practice Address - Street 1:12218 CUSTER ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4451
Practice Address - Country:US
Practice Address - Phone:909-252-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT119207106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist