Provider Demographics
NPI:1396192563
Name:YOUNG, PHILIP
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 LAKE PARK LANE
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101
Mailing Address - Country:US
Mailing Address - Phone:470-578-4772
Mailing Address - Fax:
Practice Address - Street 1:4841 LAKE PARK LANE
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101
Practice Address - Country:US
Practice Address - Phone:470-578-4772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0018472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer