Provider Demographics
NPI:1043790439
Name:YOUNG, MAKEDA NAOMI
Entity Type:Individual
Prefix:
First Name:MAKEDA
Middle Name:NAOMI
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 WINDSAIL LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6213
Mailing Address - Country:US
Mailing Address - Phone:209-684-5716
Mailing Address - Fax:
Practice Address - Street 1:4935 SOUTHFRONT RD STE C
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-9829
Practice Address - Country:US
Practice Address - Phone:209-684-5716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75473225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist