Provider Demographics
NPI:1669131082
Name:YOUNGBLUTH, ELISSA JEAN-MARIE (LMT)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:JEAN-MARIE
Last Name:YOUNGBLUTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 N FARWELL LN APT 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1180
Mailing Address - Country:US
Mailing Address - Phone:208-866-8757
Mailing Address - Fax:
Practice Address - Street 1:1915 N FARWELL LN APT 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1180
Practice Address - Country:US
Practice Address - Phone:208-866-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4223225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist