Provider Demographics
NPI:1902840655
Name:YOUNGBLOOD, LESLIE M (OT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:SHANNON
Other - Last Name:MCCORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:O T
Mailing Address - Street 1:4517 SOUTHLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3280
Mailing Address - Country:US
Mailing Address - Phone:205-985-4111
Mailing Address - Fax:205-985-4326
Practice Address - Street 1:4517 SOUTHLAKE PKWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244-3280
Practice Address - Country:US
Practice Address - Phone:205-985-4111
Practice Address - Fax:205-985-4326
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1737225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51528045OtherBLUE CROSS
Q44704Medicare UPIN
0515560200YOUMedicare ID - Type Unspecified