Provider Demographics
NPI:1619275971
Name:YOUNGBLOOD, MELISSA N
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:N
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:CUDNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12232 CAVELL ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-2306
Mailing Address - Country:US
Mailing Address - Phone:906-440-7119
Mailing Address - Fax:
Practice Address - Street 1:46200 PORT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6048
Practice Address - Country:US
Practice Address - Phone:734-454-0866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI71011005290235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist