Healthcare Provider Details

I. General information

NPI: 1093859332
Provider Name (Legal Business Name): ASSOCIATED COUNSELING SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 EDGERTON ST
LITTLE CANADA MN
55117-1620
US

IV. Provider business mailing address

2625 EDGERTON ST
LITTLE CANADA MN
55117-1620
US

V. Phone/Fax

Practice location:
  • Phone: 651-484-1544
  • Fax: 651-415-1337
Mailing address:
  • Phone: 651-484-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberLP1096
License Number StateMN

VIII. Authorized Official

Name: DR. GAIL ROSE MAUDAL
Title or Position: PRESIDENT
Credential: PH.D., L.P.
Phone: 651-484-1544