Provider Demographics
NPI:1003219833
Name:YOUNGBLOOD, DENA DOREEN (LMT)
Entity Type:Individual
Prefix:MS
First Name:DENA
Middle Name:DOREEN
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24241 S LARKIN RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97004-9606
Mailing Address - Country:US
Mailing Address - Phone:503-956-0491
Mailing Address - Fax:503-632-5157
Practice Address - Street 1:408 HILDA ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2895
Practice Address - Country:US
Practice Address - Phone:503-908-1864
Practice Address - Fax:503-632-5157
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16814225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16814OtherOREGON BOARD OF MASSAGE THERAPY LICENSE