Provider Demographics
NPI:1679669436
Name:YULY, STEVEN GALE (MPT)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:GALE
Last Name:YULY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 E COMISKY ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5301
Mailing Address - Country:US
Mailing Address - Phone:208-939-3332
Mailing Address - Fax:208-939-3338
Practice Address - Street 1:457 S FITNESS PL
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6568
Practice Address - Country:US
Practice Address - Phone:208-939-3332
Practice Address - Fax:208-939-3338
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT 1607225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TC530OtherBLUE CROSS
000010142240OtherBLUE SHIELD
ID8071990000Medicaid
000010142240OtherBLUE SHIELD