Provider Demographics
NPI:1841230596
Name:DEYOUNG, LISA JOY (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JOY
Last Name:DEYOUNG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 WACCAMAW PATH
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-9433
Mailing Address - Country:US
Mailing Address - Phone:336-788-4225
Mailing Address - Fax:
Practice Address - Street 1:102 WOODLYN DR
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-6673
Practice Address - Country:US
Practice Address - Phone:336-677-1800
Practice Address - Fax:336-677-1802
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7213013Medicaid