Provider Demographics
NPI:1114710795
Name:YOUNGBLOOD, ANTONESHA LATRICE
Entity type:Individual
Prefix:
First Name:ANTONESHA
Middle Name:LATRICE
Last Name:YOUNGBLOOD
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7249 MOUNTAIN LAUREL WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9312
Mailing Address - Country:US
Mailing Address - Phone:404-397-8773
Mailing Address - Fax:
Practice Address - Street 1:7249 MOUNTAIN LAUREL WAY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9312
Practice Address - Country:US
Practice Address - Phone:404-397-8773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty