Healthcare Provider Details

I. General information

NPI: 1376101352
Provider Name (Legal Business Name): YVONNE TORA MCINTOSH LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 LILAC DR N STE 151
GOLDEN VALLEY MN
55422-4536
US

IV. Provider business mailing address

23 1/2 ROSE AVE E
SAINT PAUL MN
55117-5023
US

V. Phone/Fax

Practice location:
  • Phone: 763-525-9919
  • Fax: 763-486-4436
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21980
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: