Healthcare Provider Details

I. General information

NPI: 1114570033
Provider Name (Legal Business Name): TRANSFORMATIONAL PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 WATER ST RM 201
EXCELSIOR MN
55331-1824
US

IV. Provider business mailing address

5385 SHADY HILLS CIR
EXCELSIOR MN
55331-9157
US

V. Phone/Fax

Practice location:
  • Phone: 612-710-3874
  • Fax:
Mailing address:
  • Phone: 612-710-3874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAREN ILVEDSON
Title or Position: PSYCHOTHERAPIST, OWNER
Credential: MA, LPCC
Phone: 612-710-3874