Provider Demographics
NPI:1013586098
Name:YOUNGBLOOD, DEBORAH LEE
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21700 NORTHWESTERN HWY STE 900
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4906
Mailing Address - Country:US
Mailing Address - Phone:248-556-9156
Mailing Address - Fax:248-556-9103
Practice Address - Street 1:24463 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2931
Practice Address - Country:US
Practice Address - Phone:586-556-9156
Practice Address - Fax:248-556-9103
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001162225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant