Provider Demographics
NPI:1538359682
Name:YOUNGBLOOD, LYNELL BENNETT (BA, CADCII, NCACII)
Entity type:Individual
Prefix:
First Name:LYNELL
Middle Name:BENNETT
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:BA, CADCII, NCACII
Other - Prefix:
Other - First Name:LYNELL
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, CADCII, NCACII
Mailing Address - Street 1:4545 GEORGETOWN PL
Mailing Address - Street 2:STE F-36
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6215
Mailing Address - Country:US
Mailing Address - Phone:209-953-8900
Mailing Address - Fax:209-953-8816
Practice Address - Street 1:4545 GEORGETOWN PL
Practice Address - Street 2:STE F-36
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6215
Practice Address - Country:US
Practice Address - Phone:209-953-8900
Practice Address - Fax:209-953-8816
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA3163282101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)