Provider Demographics
NPI:1831296862
Name:YOUNG, BEVERLY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:ANN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1603
Mailing Address - Country:US
Mailing Address - Phone:573-359-2484
Mailing Address - Fax:
Practice Address - Street 1:1120 FALCON DR
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3825
Practice Address - Country:US
Practice Address - Phone:573-888-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant