Provider Demographics
NPI:1811109622
Name:YOUNG, ALICIA (LPTA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 FEATHERBONE AVE
Mailing Address - Street 2:
Mailing Address - City:THREE OAKS
Mailing Address - State:MI
Mailing Address - Zip Code:49128-1171
Mailing Address - Country:US
Mailing Address - Phone:219-878-5667
Mailing Address - Fax:219-477-4572
Practice Address - Street 1:109 FEATHERBONE AVE
Practice Address - Street 2:
Practice Address - City:THREE OAKS
Practice Address - State:MI
Practice Address - Zip Code:49128-1171
Practice Address - Country:US
Practice Address - Phone:219-878-5667
Practice Address - Fax:219-477-4572
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000802A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200660000Medicaid