Provider Demographics
NPI:1629287354
Name:YOUNGBERG, MATTHEW SHERMAN (LMFT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:SHERMAN
Last Name:YOUNGBERG
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 S YELLOWSTONE HWY #304
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5294
Mailing Address - Country:US
Mailing Address - Phone:208-313-7464
Mailing Address - Fax:208-907-0972
Practice Address - Street 1:859 S YELLOWSTONE HWY #304
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5294
Practice Address - Country:US
Practice Address - Phone:208-313-7464
Practice Address - Fax:208-907-0972
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLFMT-3748106H00000X
IDLMFT-37481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002648300Medicaid