Healthcare Provider Details

I. General information

NPI: 1194184465
Provider Name (Legal Business Name): CHJL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 PENN AVE S STE 252
BLOOMINGTON MN
55431-1358
US

IV. Provider business mailing address

8120 PENN AVE S STE. 252
BLOOMINGTON MN
55437
US

V. Phone/Fax

Practice location:
  • Phone: 612-251-4753
  • Fax: 651-730-6657
Mailing address:
  • Phone: 612-251-4753
  • Fax: 651-730-6657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC00282
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4714
License Number StateMN

VIII. Authorized Official

Name: MS. LOUISE PHELPS PAGE
Title or Position: PSYCHOTHERAPIST/PARTNER
Credential: LPCC
Phone: 612-251-4753