1518053834 NPI number — FAMILY ADOLESCENTS AND CHILDREN THERAPY SERVICES INC.

Table of content: (NPI 1518053834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518053834 NPI number — FAMILY ADOLESCENTS AND CHILDREN THERAPY SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY ADOLESCENTS AND CHILDREN THERAPY SERVICES INC.
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:
1518053834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1385 MENDOTA HEIGHTS RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOTA HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55120-1289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-379-9800
Provider Business Mailing Address Fax Number:
651-405-0358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4655 NICOLS RD
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-936-2800
Provider Business Practice Location Address Fax Number:
651-405-0358
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAN BLARCUM
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
952-938-2600

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  7571675 , 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: 326658301 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 326658300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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