Basic Information
| Provider Information | |||||||||
| NPI: | 1730642174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | NELL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DENOMIE | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | NELL | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10778 E RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | OLIVE BRANCH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386544359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014914934 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3960 NEW COVINGTON PIKE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381282504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015165320 | ||||||||
| FaxNumber: | 9015165099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 02193 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.