Provider Demographics
NPI:1447614953
Name:YOUNG, ANGIE R (7501001553)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:F
Credentials:7501001553
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10907 96TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-9646
Mailing Address - Country:US
Mailing Address - Phone:616-848-6219
Mailing Address - Fax:
Practice Address - Street 1:10907 96TH AVE
Practice Address - Street 2:
Practice Address - City:WEST OLIVE
Practice Address - State:MI
Practice Address - Zip Code:49460-9646
Practice Address - Country:US
Practice Address - Phone:616-848-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501001553225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist