Provider Demographics
NPI:1023360104
Name:YOUNGBERG, KURT (LCSW)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:YOUNGBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 SILVERTHORN DR NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1062
Mailing Address - Country:US
Mailing Address - Phone:714-482-5472
Mailing Address - Fax:
Practice Address - Street 1:109 ANDERSON ST SE STE 101
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8610
Practice Address - Country:US
Practice Address - Phone:714-482-5472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8375190-35021041C0700X
GACSW0061521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical