Provider Demographics
NPI:1215296405
Name:YOUNGBAUER, MARA L (LPCIT)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:L
Last Name:YOUNGBAUER
Suffix:
Gender:F
Credentials:LPCIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W151N8714 MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3109
Mailing Address - Country:US
Mailing Address - Phone:262-893-3615
Mailing Address - Fax:
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 650
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-771-9304
Practice Address - Fax:414-771-9543
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1206226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588710073Medicaid