Provider Demographics
NPI:1962895920
Name:YOUNG, JUSTIN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 NEW LONDON CT APT 510
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-5312
Mailing Address - Country:US
Mailing Address - Phone:906-360-9977
Mailing Address - Fax:
Practice Address - Street 1:3101 NEW LONDON CT APT 510
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-5312
Practice Address - Country:US
Practice Address - Phone:906-360-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003184A2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer