Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1437407947 |
---|---|
Provider Name | Matt Youngberg |
First Address | Broken Arrow, OK 74011-8272 |
Second Address | Broken Arrow, OK 74011-8272 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2012 |
Last Update Date | 15/08/2012 |