Healthcare Provider Details

I. General information

NPI: 1558414136
Provider Name (Legal Business Name): SALLY IRENE BECK LMFT, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 1ST ST E
JORDAN MN
55352-1502
US

IV. Provider business mailing address

110 1ST ST E
JORDAN MN
55352-1502
US

V. Phone/Fax

Practice location:
  • Phone: 952-451-3660
  • Fax: 952-582-1666
Mailing address:
  • Phone: 952-451-3660
  • Fax: 952-582-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1739
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: