Provider Demographics
NPI:1316104102
Name:YOUNG, KIMBERLY R (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 E STATE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-4365
Mailing Address - Country:US
Mailing Address - Phone:419-332-6840
Mailing Address - Fax:419-332-6929
Practice Address - Street 1:1320 E STATE ST
Practice Address - Street 2:SUITE B
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-4365
Practice Address - Country:US
Practice Address - Phone:419-332-6840
Practice Address - Fax:419-332-6929
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH016520174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist