MEDICARE: KATRINA RENISE YOUNG LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1811	SC
2	225200000X	Physical Therapy Assistant	PTA8510	CA

General Provider Information

NPI Number	:	1225206196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA RENISE YOUNG LPTA

Provider Business Mailing Address
First Line	:	528 ARCOLA DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-5407
Country	:	US
Telephone Number	:	803-736-1759
Fax Number	:	803-736-0374

Provider Business Practice Location Address
First Line	:	528 ARCOLA DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-5407
Country	:	US
Telephone Number	:	803-736-1759
Fax Number	:	803-736-0374

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2008
Last Update Date	:	02/16/2017

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