Provider Demographics
NPI:1558823203
Name:YOUNGBLOOD, GREGGORY (LAC)
Entity Type:Individual
Prefix:
First Name:GREGGORY
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:GROSSE TETE
Mailing Address - State:LA
Mailing Address - Zip Code:70740-0383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10508 N GLENSTONE PL
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2838
Practice Address - Country:US
Practice Address - Phone:225-349-8696
Practice Address - Fax:225-349-8698
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC5086101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)