Healthcare Provider Details

I. General information

NPI: 1922473479
Provider Name (Legal Business Name): THOMAS YOUNGBERG MSW, LCSW, LPHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W KENWOOD AVE STE 100
DECATUR IL
62526-4379
US

IV. Provider business mailing address

201 E MADISON ST STE 328
SPRINGFIELD IL
62702-5131
US

V. Phone/Fax

Practice location:
  • Phone: 217-872-3800
  • Fax: 217-872-0849
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.018052
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: