Provider Demographics
NPI:1396898979
Name:YOUNGER, STACY (MPT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:YOUNGER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 AMBER DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5556
Mailing Address - Country:US
Mailing Address - Phone:970-674-1186
Mailing Address - Fax:
Practice Address - Street 1:1678 PLATTE RIVER DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-3376
Practice Address - Country:US
Practice Address - Phone:970-213-3097
Practice Address - Fax:970-674-1186
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CO6996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94932212Medicaid