Provider Demographics
NPI:1528201290
Name:YOUNGBLOOD, TERESA (LMT #16176)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:LMT #16176
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 GABLE RD APT 19
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-2951
Mailing Address - Country:US
Mailing Address - Phone:503-366-8084
Mailing Address - Fax:503-366-8084
Practice Address - Street 1:430 COLUMBIA BOULIVARD
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051
Practice Address - Country:US
Practice Address - Phone:503-366-8084
Practice Address - Fax:503-366-8084
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16176225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist