=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598246290
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. PHYLLIS LOUISE YOUNG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2018
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 NE BRENNAN LN
-----------------------------------------------------
City | PRINEVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-508-8533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 NE BRENNAN LN
-----------------------------------------------------
City | PRINEVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97754-9283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-508-8533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 07138
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------