Provider Demographics
NPI:1730642174
Name:YOUNG, MARY NELL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:NELL
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:NELL
Other - Last Name:DENOMIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10778 E RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-4359
Mailing Address - Country:US
Mailing Address - Phone:901-491-4934
Mailing Address - Fax:
Practice Address - Street 1:3960 NEW COVINGTON PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2504
Practice Address - Country:US
Practice Address - Phone:901-516-5320
Practice Address - Fax:901-516-5099
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN02193225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant