1104038215 NPI number — CENTER FOR MINDFUL DIALOGUE, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104038215 NPI number — CENTER FOR MINDFUL DIALOGUE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR MINDFUL DIALOGUE, PA
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:
1104038215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
416 E HENNEPIN AVE
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55414-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-379-5360
Provider Business Mailing Address Fax Number:
612-379-5353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 E HENNEPIN AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55414-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-379-5360
Provider Business Practice Location Address Fax Number:
612-379-5353
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
SUSAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
612-379-5360

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP1749 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02849CO . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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