Provider Demographics
NPI:1477726784
Name:YOUNG, TERESA L (OT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 E 29TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2169
Mailing Address - Country:US
Mailing Address - Phone:316-634-8710
Mailing Address - Fax:316-634-8891
Practice Address - Street 1:8700 E 29TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2169
Practice Address - Country:US
Practice Address - Phone:316-634-8710
Practice Address - Fax:316-634-8891
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-01808225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201262360AMedicaid