Provider Demographics
NPI:1841780459
Name:YOUNGBLOOD, GARYSHA JOY
Entity Type:Individual
Prefix:
First Name:GARYSHA
Middle Name:JOY
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1121
Mailing Address - Country:US
Mailing Address - Phone:510-446-7100
Mailing Address - Fax:
Practice Address - Street 1:2545 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1121
Practice Address - Country:US
Practice Address - Phone:510-446-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115328106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist