Healthcare Provider Details

I. General information

NPI: 1356159891
Provider Name (Legal Business Name): MODERN THERAPEUTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 DIVISION ST S
NORTHFIELD MN
55057-2020
US

IV. Provider business mailing address

502 DIVISION ST S
NORTHFIELD MN
55057-2020
US

V. Phone/Fax

Practice location:
  • Phone: 612-488-2248
  • Fax: 612-488-2248
Mailing address:
  • Phone: 612-488-2248
  • Fax: 612-488-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREA BERUBE
Title or Position: OWNER
Credential: CRNA
Phone: 612-616-7731