Provider Demographics
NPI:1528151156
Name:YOUNGBERG, CHRISTOPHER JON (LMFT, PHD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JON
Last Name:YOUNGBERG
Suffix:
Gender:M
Credentials:LMFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5880
Mailing Address - Country:US
Mailing Address - Phone:208-552-3251
Mailing Address - Fax:
Practice Address - Street 1:2250 FIELDSTONE DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83401-5880
Practice Address - Country:US
Practice Address - Phone:208-552-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT2860106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010145467OtherREGENCE BLUE SHIELD OF ID