Provider Demographics
NPI:1255747820
Name:YOUNG, KRISTY
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:HOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:340 OLYMPIC CT
Mailing Address - Street 2:APT 17
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 OLYMPIC CT
Practice Address - Street 2:APT 17
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1811
Practice Address - Country:US
Practice Address - Phone:618-980-5695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist