Provider Demographics
NPI:1073725719
Name:YOUNG, LEWAYNE A (COTA)
Entity type:Individual
Prefix:MR
First Name:LEWAYNE
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ALACHUA DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:34112
Mailing Address - Country:US
Mailing Address - Phone:863-412-0320
Mailing Address - Fax:
Practice Address - Street 1:132 ALACHUA DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1404
Practice Address - Country:US
Practice Address - Phone:863-412-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA9537224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant