Provider Demographics
NPI:1922518182
Name:YOUNGBLOOD, GLORIA LYNN (CDPT)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:LYNN
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13222 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98168-2807
Mailing Address - Country:US
Mailing Address - Phone:206-769-7295
Mailing Address - Fax:
Practice Address - Street 1:1305 TACOMA AVE S STE 305
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1903
Practice Address - Country:US
Practice Address - Phone:253-396-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60559177101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty