Healthcare Provider Details

I. General information

NPI: 1679772339
Provider Name (Legal Business Name): LORI E YOUNG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 LAFAYETTE ST STE C
MARIANNA FL
32446-8231
US

IV. Provider business mailing address

2917B OPTIMIST DR
MARIANNA FL
32448-7794
US

V. Phone/Fax

Practice location:
  • Phone: 850-526-6221
  • Fax: 850-526-1803
Mailing address:
  • Phone: 850-526-3067
  • Fax: 850-526-3086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 18736
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: