Provider Demographics
NPI:1407191166
Name:YOUNGBLOOD, BRIAN JAMES (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CENTRAL PARK W
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7659
Mailing Address - Country:US
Mailing Address - Phone:443-562-7137
Mailing Address - Fax:
Practice Address - Street 1:320 CENTRAL PARK W
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7659
Practice Address - Country:US
Practice Address - Phone:443-562-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078824104100000X
NY0804431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker