Provider Demographics
NPI:1851530133
Name:YOUNG, MARY LOU (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARY LOU
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 236
Mailing Address - Street 2:2814 GARDNER RD
Mailing Address - City:POMPEY
Mailing Address - State:NY
Mailing Address - Zip Code:13138
Mailing Address - Country:US
Mailing Address - Phone:315-430-3942
Mailing Address - Fax:
Practice Address - Street 1:4583 NORTH ST
Practice Address - Street 2:
Practice Address - City:JAMESVILLE
Practice Address - State:NY
Practice Address - Zip Code:13078-9461
Practice Address - Country:US
Practice Address - Phone:315-430-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013872225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist