Provider Demographics
NPI:1427483189
Name:YOUNGBLOOD, KAITLIN ANN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ANN
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 BEISER BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-7793
Mailing Address - Country:US
Mailing Address - Phone:302-674-4375
Mailing Address - Fax:
Practice Address - Street 1:230 BEISER BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-7793
Practice Address - Country:US
Practice Address - Phone:302-674-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0012345225100000X
DEJ1-0003036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE#321262ZBSXMedicare PIN
DEPTAN#G00716Medicare PIN