Provider Demographics
NPI:1942713060
Name:YOUNG, WANDA SUE (LMT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:SUE
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 1:345 LAWSON MILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-4523
Mailing Address - Country:US
Mailing Address - Phone:865-963-1775
Mailing Address - Fax:
Practice Address - Street 1:345 LAWSON MILL RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-4523
Practice Address - Country:US
Practice Address - Phone:865-963-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11711225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist