Provider Demographics
NPI:1548878341
Name:YOUNG, MCKENNA BRIANE (PT)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:BRIANE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6175 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:DALTON GARDENS
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9603
Mailing Address - Country:US
Mailing Address - Phone:208-819-7837
Mailing Address - Fax:
Practice Address - Street 1:8382 N WAYNE DR STE 204
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6028
Practice Address - Country:US
Practice Address - Phone:208-719-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-67912251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty