Provider Demographics
NPI:1265682801
Name:YOUNG, KELLY SHANNON (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SHANNON
Last Name:YOUNG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 ROBESON STREET
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-5566
Mailing Address - Country:US
Mailing Address - Phone:508-646-9525
Mailing Address - Fax:508-558-4149
Practice Address - Street 1:1151 ROBESON STREET
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5566
Practice Address - Country:US
Practice Address - Phone:508-646-9525
Practice Address - Fax:508-558-4149
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02324225100000X
MA18194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist