Healthcare Provider Details

I. General information

NPI: 1609667005
Provider Name (Legal Business Name): CRYSTAL YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 OLD COUNTRY RD SE
PALM BAY FL
32909-6903
US

IV. Provider business mailing address

674 OLD COUNTRY RD SE
PALM BAY FL
32909-6903
US

V. Phone/Fax

Practice location:
  • Phone: 321-806-9395
  • Fax:
Mailing address:
  • Phone: 321-806-9395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA13514
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: