Provider Demographics
NPI:1982987194
Name:VIDALI YOUNG, MARTINA (DPT)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:VIDALI YOUNG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 BROOKHURST AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2642
Mailing Address - Country:US
Mailing Address - Phone:303-704-6334
Mailing Address - Fax:
Practice Address - Street 1:4348 WOODLANDS BLVD
Practice Address - Street 2:#100
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-2800
Practice Address - Country:US
Practice Address - Phone:303-781-7511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist