Healthcare Provider Details

I. General information

NPI: 1043517451
Provider Name (Legal Business Name): KIMBERLY J YOUNGBLOOD LICDC, ICDAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 NORTHLAND BLVD
CINCINNATI OH
45240-3214
US

IV. Provider business mailing address

7753 BITTEROOT LN
CINCINNATI OH
45224-1172
US

V. Phone/Fax

Practice location:
  • Phone: 513-549-2681
  • Fax: 513-445-8286
Mailing address:
  • Phone: 513-505-4145
  • Fax: 513-445-8286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number081242
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: