Provider Demographics
NPI:1922289479
Name:YOUNGBLOOD, WILLIAM MICHAEL DIBBLE (MFT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL DIBBLE
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:MICHAEL
Other - Last Name:DIBBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7825 HIGHLAND VILLAGE PL # 467
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-5182
Mailing Address - Country:US
Mailing Address - Phone:619-820-0307
Mailing Address - Fax:858-538-0309
Practice Address - Street 1:9815 CARROLL CANYON RD
Practice Address - Street 2:STE. 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1123
Practice Address - Country:US
Practice Address - Phone:619-820-0307
Practice Address - Fax:858-538-0309
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44659106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist