MEDICARE: EQUILIBRIYA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	3313	MN
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	303560	MN
3	106H00000X	Marriage & Family Therapist	3313	MN
4	101Y00000X	Counselor	81	MN

General Provider Information

NPI Number	:	1801376587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EQUILIBRIYA, LLC

Provider Business Mailing Address
First Line	:	105 NEW ENGLAND PL STE 150
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082-2036
Country	:	US
Telephone Number	:	651-342-2175
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 NEW ENGLAND PL STE 150
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082-2036
Country	:	US
Telephone Number	:	651-342-2175
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	WENDY LEE MCMAHON
Credential	:	LMFT, LADC, CST
Telephone Number	:	651-342-2175

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	08/21/2018

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Directions to “EQUILIBRIYA, LLC ” Practice Location

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