Healthcare Provider Details

I. General information

NPI: 1356040901
Provider Name (Legal Business Name): COLLEEN FAFINSKI LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHASKA CREEK WAY STE 200
CHASKA MN
55318-2749
US

IV. Provider business mailing address

4200 DAHLBERG DR STE 300
GOLDEN VALLEY MN
55422-4841
US

V. Phone/Fax

Practice location:
  • Phone: 952-856-1046
  • Fax: 952-847-4067
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0230
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: