Provider Demographics
NPI:1366063687
Name:YOUNG, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6292 E 200 S
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-9123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2905 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4078
Practice Address - Country:US
Practice Address - Phone:765-419-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004583A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant