Provider Demographics
NPI:1649534264
Name:YOUNGBLOOD, MARISA (MSW)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24445 NORHTWESTERN HIGHWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-483-7804
Mailing Address - Fax:248-483-7868
Practice Address - Street 1:24445 NORHTWESTERN HIGHWAY 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:248-483-7868
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010213321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical