Healthcare Provider Details

I. General information

NPI: 1962526517
Provider Name (Legal Business Name): KEITH A. YOUNGBLOOD PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7331 CLAIRBORNE DR
ANCHORAGE AK
99502-7119
US

IV. Provider business mailing address

7331 CLAIRBORNE DR
ANCHORAGE AK
99502-7119
US

V. Phone/Fax

Practice location:
  • Phone: 907-301-2992
  • Fax: 907-222-5254
Mailing address:
  • Phone: 907-301-2992
  • Fax: 907-222-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number461
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: