Provider Demographics
NPI:1972099539
Name:YOUNGBLOOD, STACY LEANN (COTA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEANN
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 COUNTY ROAD 202
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-6753
Mailing Address - Country:US
Mailing Address - Phone:903-690-6756
Mailing Address - Fax:
Practice Address - Street 1:1323 COUNTY ROAD 202
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-6753
Practice Address - Country:US
Practice Address - Phone:903-690-6756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213272224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant