Provider Demographics
NPI:1417637125
Name:YOUNG, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
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 1:98 GARDENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 UNION RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1400
Practice Address - Country:US
Practice Address - Phone:716-456-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist