Provider Demographics
NPI:1689703498
Name:YOUNGBLOOD, ELISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5771
Mailing Address - Country:US
Mailing Address - Phone:907-617-0169
Mailing Address - Fax:
Practice Address - Street 1:1162 JACKSON ST
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5771
Practice Address - Country:US
Practice Address - Phone:907-617-0169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK568103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical