Provider Demographics
NPI:1205317286
Name:YOUNGBLOOD, FELICIA (COTA)
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
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 1:1217 SULLIVAN DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-7341
Mailing Address - Country:US
Mailing Address - Phone:214-587-6860
Mailing Address - Fax:
Practice Address - Street 1:8615 LULLWATER DRI
Practice Address - Street 2:
Practice Address - City:DALLAS,
Practice Address - State:TX
Practice Address - Zip Code:75238
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2091532251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology