MEDICARE: CHAUTAUQUA N 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	2055893	TX

General Provider Information

NPI Number	:	1366719155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAUTAUQUA N YOUNG LPTA

Provider Business Mailing Address
First Line	:	7103 MYNA DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-3385
Country	:	US
Telephone Number	:	469-223-9479
Fax Number	:

Provider Business Practice Location Address
First Line	:	5601 BRIDGE ST STE 490
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76112-2306
Country	:	US
Telephone Number	:	817-446-5000
Fax Number	:

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

Provider Enumeration Date	:	11/21/2011
Last Update Date	:	11/21/2011

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