1629108410 NPI number — LACUNA FOR INTEGRATIVE THERAPIES

Table of content: (NPI 1629108410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629108410 NPI number — LACUNA FOR INTEGRATIVE THERAPIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LACUNA FOR INTEGRATIVE THERAPIES
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:
6
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:
1629108410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5009 EXCELSIOR BLVD
Provider Second Line Business Mailing Address:
SUITE 134
Provider Business Mailing Address City Name:
ST. LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-360-5685
Provider Business Mailing Address Fax Number:
952-285-4103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5009 EXCELSIOR BLVD
Provider Second Line Business Practice Location Address:
SUITE 134
Provider Business Practice Location Address City Name:
ST. LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-360-5685
Provider Business Practice Location Address Fax Number:
952-285-4103
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KENT
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
LICSW
Authorized Official Telephone Number:
651-264-0260

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  15118 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X , with the licence number: 15118 , 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: 607649100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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