Healthcare Provider Details

I. General information

NPI: 1053485904
Provider Name (Legal Business Name): ATTACHMENT AND FAMILY CENTER OF MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 05/10/2020
Certification Date: 05/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N CHESTNUT ST
CHASKA MN
55318-1918
US

IV. Provider business mailing address

102 N CHESTNUT ST
CHASKA MN
55318-1918
US

V. Phone/Fax

Practice location:
  • Phone: 952-475-2818
  • Fax: 952-475-3356
Mailing address:
  • Phone: 952-475-2818
  • Fax: 952-475-3356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY TODD NICHOLS
Title or Position: EXESCUTIVE DIRECTOR
Credential:
Phone: 952-234-4632