Healthcare Provider Details

I. General information

NPI: 1811061294
Provider Name (Legal Business Name): CARLA SUE YOUNG OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 JACKSON DR
VINCENNES IN
47591-5921
US

IV. Provider business mailing address

2018 JACKSON DR
VINCENNES IN
47591-5921
US

V. Phone/Fax

Practice location:
  • Phone: 812-882-6341
  • Fax:
Mailing address:
  • Phone: 812-882-6341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number31001784A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: