Provider Demographics
NPI:1225206196
Name:YOUNG, KATRINA RENISE (LPTA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:RENISE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 ARCOLA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-5407
Mailing Address - Country:US
Mailing Address - Phone:803-736-1759
Mailing Address - Fax:803-736-0374
Practice Address - Street 1:528 ARCOLA DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5407
Practice Address - Country:US
Practice Address - Phone:803-736-1759
Practice Address - Fax:803-736-0374
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1811225200000X
CAPTA8510225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant