Healthcare Provider Details

I. General information

NPI: 1770194417
Provider Name (Legal Business Name): VAYDA MENTAL HEALTH COLLABORATIVE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 COON RAPIDS BLVD NW STE 100
COON RAPIDS MN
55433-5869
US

IV. Provider business mailing address

13233 JOHNSON ST NE
BLAINE MN
55434-4171
US

V. Phone/Fax

Practice location:
  • Phone: 651-240-2206
  • Fax: 612-446-5766
Mailing address:
  • Phone: 612-382-9781
  • Fax: 612-446-5766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. ALISE MARIE NOVAK
Title or Position: CO-FOUNDER
Credential: PSYD, LP
Phone: 651-240-2206