Provider Demographics
NPI:1619650876
Name:YOUNGBERG, CORA ANN
Entity Type:Individual
Prefix:
First Name:CORA
Middle Name:ANN
Last Name:YOUNGBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 N NORBECK ST APT 131
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2860
Mailing Address - Country:US
Mailing Address - Phone:605-291-9781
Mailing Address - Fax:
Practice Address - Street 1:717 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-3312
Practice Address - Country:US
Practice Address - Phone:605-494-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6434101YM0800X, 104100000X
IA121337101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health