Healthcare Provider Details

I. General information

NPI: 1114859857
Provider Name (Legal Business Name): MACI LAW NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 NORMANDALE RD STE 1
EDINA MN
55424-1572
US

IV. Provider business mailing address

5701 NORMANDALE RD
EDINA MN
55424-2401
US

V. Phone/Fax

Practice location:
  • Phone: 952-848-4000
  • Fax: 952-848-4801
Mailing address:
  • Phone: 952-848-4000
  • Fax: 952-848-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1034701
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: