Provider Demographics
NPI:1043517451
Name:YOUNGBLOOD, KIMBERLY J (LICDC, ICDAC)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:J
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:LICDC, ICDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7753 BITTEROOT LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45224-1172
Mailing Address - Country:US
Mailing Address - Phone:513-505-4145
Mailing Address - Fax:513-445-8286
Practice Address - Street 1:690 NORTHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-3214
Practice Address - Country:US
Practice Address - Phone:513-549-2681
Practice Address - Fax:513-445-8286
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OH081242101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0334355Medicaid