Healthcare Provider Details

I. General information

NPI: 1073165569
Provider Name (Legal Business Name): ANGELA SUZANNE ELMENDORF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7975 STONE CREEK DR STE 130
CHANHASSEN MN
55317-4728
US

IV. Provider business mailing address

10201 WAYZATA BLVD STE 100
MINNETONKA MN
55305-1500
US

V. Phone/Fax

Practice location:
  • Phone: 953-544-6806
  • Fax: 952-545-0098
Mailing address:
  • Phone: 953-544-6806
  • Fax: 952-545-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5503
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: