Provider Demographics
NPI:1568935245
Name:KENNETH G YOUNGBERG PC
Entity Type:Organization
Organization Name:KENNETH G YOUNGBERG PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:YOUNGBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:907-953-7303
Mailing Address - Street 1:47360 PHILOSOPHER CT
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-9259
Mailing Address - Country:US
Mailing Address - Phone:907-953-7303
Mailing Address - Fax:
Practice Address - Street 1:232 W ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7411
Practice Address - Country:US
Practice Address - Phone:907-953-7303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-06
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health