Provider Demographics
NPI:1275664666
Name:DEYOUNG, ERIC (OT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:DEYOUNG
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13100 EASTPOINT PARK BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3157
Mailing Address - Country:US
Mailing Address - Phone:502-245-0767
Mailing Address - Fax:502-245-1380
Practice Address - Street 1:13100 EASTPOINT PARK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3157
Practice Address - Country:US
Practice Address - Phone:502-245-0767
Practice Address - Fax:502-245-1380
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1714225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000343513OtherANTHEM
KY0988301Medicare ID - Type UnspecifiedMEDICARE ID