Provider Demographics
NPI:1982379541
Name:YOUNG, SUSAN LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6705 SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-9601
Mailing Address - Country:US
Mailing Address - Phone:920-284-8988
Mailing Address - Fax:
Practice Address - Street 1:W6705 SCHOOL RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-9601
Practice Address - Country:US
Practice Address - Phone:920-284-8988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1179-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant