Healthcare Provider Details

I. General information

NPI: 1407561582
Provider Name (Legal Business Name): MIDWEST AUTISM & PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 XERXES AVE S STE 110
BLOOMINGTON MN
55431-1200
US

IV. Provider business mailing address

227 TOWER AVE
DUNDAS MN
55019-3989
US

V. Phone/Fax

Practice location:
  • Phone: 763-607-7817
  • Fax: 612-662-8779
Mailing address:
  • Phone: 763-607-7817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MEGAN MANTY
Title or Position: OWNER
Credential: LPCC
Phone: 763-607-7817