Basic Information
| Provider Information | |||||||||
| NPI: | 1962431205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNGMAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | LEONARD | ||||||||
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| Credential: | MA, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 EAST FIRST STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284404 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188794559 | ||||||||
| FaxNumber: | 2188790282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 05/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP0694 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 207048100 | 05 | MN | MEDICAID |