Basic Information
| Provider Information | |||||||||
| NPI: | 1255905055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 MAYBROOK RD STE L | ||||||||
| Address2: | |||||||||
| City: | CAMPBELL HALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109162741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456364344 | ||||||||
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| Practice Location | |||||||||
| Address1: | 745 STATE ROUTE 17M STE 104 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109502663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457823200 | ||||||||
| FaxNumber: | 8457823100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2021 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9080 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.