Provider Demographics
NPI:1689812547
Name:YOUNGBLOOD, ADELINE (MBS, LPCC)
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:MBS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E JACKSON
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743
Mailing Address - Country:US
Mailing Address - Phone:580-326-2200
Mailing Address - Fax:580-326-2201
Practice Address - Street 1:612 E JACKSON
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743
Practice Address - Country:US
Practice Address - Phone:580-326-2200
Practice Address - Fax:580-326-2201
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731526909Medicaid