Healthcare Provider Details

I. General information

NPI: 1275037277
Provider Name (Legal Business Name): EDEN THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRAIRIE CENTER DR STE 210
EDEN PRAIRIE MN
55344-7328
US

IV. Provider business mailing address

800 PRAIRIE CENTER DR STE 210
EDEN PRAIRIE MN
55344-7328
US

V. Phone/Fax

Practice location:
  • Phone: 952-234-9210
  • Fax: 952-204-3933
Mailing address:
  • Phone: 952-234-9210
  • Fax: 952-204-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC01257
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: NANCY ANN LOWE
Title or Position: OWNER
Credential:
Phone: 952-807-6516