Healthcare Provider Details

I. General information

NPI: 1992025639
Provider Name (Legal Business Name): MINNESOTA MENTAL HEALTH CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 OLEARY LN
EAGAN MN
55123-2340
US

IV. Provider business mailing address

3450 OLEARY LN
EAGAN MN
55123-2340
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-0114
  • Fax:
Mailing address:
  • Phone: 651-365-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13805
License Number StateMN

VIII. Authorized Official

Name: PATRICK DOYLE
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 651-454-0114