1649378019 NPI number — AURORA PSYCHOLOGICAL SERVICES LLC

Table of content: (NPI 1649378019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649378019 NPI number — AURORA PSYCHOLOGICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AURORA PSYCHOLOGICAL SERVICES LLC
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:
1649378019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4660 SLATER RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-4047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-882-6299
Provider Business Mailing Address Fax Number:
651-683-0057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4660 SLATER RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-4047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-882-6299
Provider Business Practice Location Address Fax Number:
651-882-6299
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EMANUEL
Authorized Official First Name:
ANNIE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
651-274-1203

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP4645 , 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: 83G50OL . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 084673200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138155 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP58813 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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