Provider Demographics
NPI:1114022258
Name:YOUNGER, RITA J (LICSW)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:J
Last Name:YOUNGER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:STE 435 S
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1052
Mailing Address - Country:US
Mailing Address - Phone:651-647-1900
Mailing Address - Fax:
Practice Address - Street 1:5821 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1487
Practice Address - Country:US
Practice Address - Phone:651-647-1900
Practice Address - Fax:651-647-1861
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3511041C0700X
MN22106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN389555600Medicaid