Healthcare Provider Details

I. General information

NPI: 1639713696
Provider Name (Legal Business Name): JOANNA M YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2019
Last Update Date: 11/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 COLORADO AVE
RIVERSIDE CA
92503-2167
US

IV. Provider business mailing address

16245 HUNTER ST
FONTANA CA
92335-7816
US

V. Phone/Fax

Practice location:
  • Phone: 951-688-3636
  • Fax:
Mailing address:
  • Phone: 909-561-6124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number47953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: