Provider Demographics
NPI:1225447295
Name:YOUNGBERG, MARY CHRISTENA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTENA
Last Name:YOUNGBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TENA
Other - Middle Name:
Other - Last Name:YOUNGBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:15600 REDMOND WAY
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15600 REDMOND WAY
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3862
Practice Address - Country:US
Practice Address - Phone:425-890-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001182101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)