1770194417 NPI number — VAYDA MENTAL HEALTH COLLABORATIVE PLLC

Table of content: (NPI 1770194417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770194417 NPI number — VAYDA MENTAL HEALTH COLLABORATIVE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VAYDA MENTAL HEALTH COLLABORATIVE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770194417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13233 JOHNSON ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55434-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-382-9781
Provider Business Mailing Address Fax Number:
612-446-5766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
299 COON RAPIDS BLVD NW STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-5869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-240-2206
Provider Business Practice Location Address Fax Number:
612-446-5766
Provider Enumeration Date:
08/16/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NOVAK
Authorized Official First Name:
ALISE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CO-FOUNDER
Authorized Official Telephone Number:
651-240-2206

Provider Taxonomy Codes

  • Taxonomy code: 103TH0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)