Provider Demographics
NPI:1134393127
Name:YOUNGBLOOD, JOAN LESLIE
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:LESLIE
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 BENTLEY ST
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8169
Mailing Address - Country:US
Mailing Address - Phone:407-366-4565
Mailing Address - Fax:407-971-8745
Practice Address - Street 1:680 BENTLEY ST
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8169
Practice Address - Country:US
Practice Address - Phone:407-366-4565
Practice Address - Fax:407-971-8745
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-21
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230328100Medicaid