Provider Demographics
NPI:1063221216
Name:YOUNGBLOOD, SCOTT BRADLEY
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:BRADLEY
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 S LAW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6338
Mailing Address - Country:US
Mailing Address - Phone:208-863-6515
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-584-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician