Healthcare Provider Details

I. General information

NPI: 1265682801
Provider Name (Legal Business Name): KELLY SHANNON YOUNG DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 03/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 ROBESON STREET
FALL RIVER MA
02720-5566
US

IV. Provider business mailing address

1151 ROBESON STREET
FALL RIVER MA
02720-5566
US

V. Phone/Fax

Practice location:
  • Phone: 508-646-9525
  • Fax: 508-558-4149
Mailing address:
  • Phone: 508-646-9525
  • Fax: 508-558-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT02324
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number18194
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: