Provider Demographics
NPI:1316685423
Name:YOUNGBERG, ALLISON (COTA/L)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:YOUNGBERG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2832 SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-7068
Mailing Address - Country:US
Mailing Address - Phone:941-585-8481
Mailing Address - Fax:
Practice Address - Street 1:101 OVERLOOK DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884
Practice Address - Country:US
Practice Address - Phone:863-268-2608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18946224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant