Provider Demographics
NPI:1366599045
Name:YOUNGBLOOD, MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 FM 1960 RD W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-3840
Mailing Address - Country:US
Mailing Address - Phone:281-664-2107
Mailing Address - Fax:281-955-5875
Practice Address - Street 1:11800 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-3840
Practice Address - Country:US
Practice Address - Phone:281-664-2107
Practice Address - Fax:281-955-5875
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPT10438262251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T3572OtherBLUE CROSS BLUE SHIELD PROVIDER RECORD ID
TX8T3572OtherBLUE CROSS BLUE SHIELD PROVIDER RECORD ID