Provider Demographics
NPI:1184343907
Name:YOUNG, SHANETRA L (MT)
Entity type:Individual
Prefix:
First Name:SHANETRA
Middle Name:L
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 AVOCADO AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7840
Mailing Address - Country:US
Mailing Address - Phone:949-386-9794
Mailing Address - Fax:
Practice Address - Street 1:1303 AVOCADO AVE STE 120
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7840
Practice Address - Country:US
Practice Address - Phone:949-386-9794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81202225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81202OtherLICENSE NUMBER