Provider Demographics
NPI:1053386474
Name:YOUNG, SALLY ANN (ATC-L)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:ANN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:ATC-L
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:314 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:IN
Mailing Address - Zip Code:46932-8791
Mailing Address - Country:US
Mailing Address - Phone:574-699-6449
Mailing Address - Fax:574-626-2172
Practice Address - Street 1:6422 E STATE ROAD 218
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:IN
Practice Address - Zip Code:46994-9303
Practice Address - Country:US
Practice Address - Phone:574-626-2511
Practice Address - Fax:574-626-2172
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000029A171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor