Provider Demographics
NPI:1891818803
Name:YOUNGBLOOD, FLETA JOY (LBSW)
Entity Type:Individual
Prefix:
First Name:FLETA
Middle Name:JOY
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT. 5 BOX 15
Mailing Address - Street 2:
Mailing Address - City:KIRBYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75956
Mailing Address - Country:US
Mailing Address - Phone:409-423-3807
Mailing Address - Fax:409-423-3807
Practice Address - Street 1:139 W LAMAR ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4014
Practice Address - Country:US
Practice Address - Phone:409-384-6829
Practice Address - Fax:409-384-4770
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19736104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker