Provider Demographics
NPI:1598246290
Name:YOUNG, PHYLLIS LOUISE
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:LOUISE
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 1:350 NE BRENNAN LN
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-9283
Mailing Address - Country:US
Mailing Address - Phone:541-508-8533
Mailing Address - Fax:
Practice Address - Street 1:350 NE BRENNAN LN
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-508-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07138225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant