Provider Demographics
NPI:1699896183
Name:YOUNG, TAMARA MICHELLE (OTR)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:MICHELLE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 RANCH TRL APT 161
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-7615
Mailing Address - Country:US
Mailing Address - Phone:972-869-9575
Mailing Address - Fax:
Practice Address - Street 1:2300 GRAVEL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118-6950
Practice Address - Country:US
Practice Address - Phone:817-589-7033
Practice Address - Fax:817-595-1178
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109584225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85065TOtherBCBS