Provider Demographics
NPI:1316612468
Name:YOUNG, TONNI (PTA)
Entity type:Individual
Prefix:
First Name:TONNI
Middle Name:
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 1:1492 MERLE AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-2175
Mailing Address - Country:US
Mailing Address - Phone:810-813-1906
Mailing Address - Fax:
Practice Address - Street 1:4764 DIXIE HWY STE 150
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3525
Practice Address - Country:US
Practice Address - Phone:248-247-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006480225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant