Healthcare Provider Details

I. General information

NPI: 1508252719
Provider Name (Legal Business Name): SEXUAL WELLNESS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2291 WATERS DR
MENDOTA HEIGHTS MN
55120-1363
US

IV. Provider business mailing address

2291 WATERS DR
MENDOTA HEIGHTS MN
55120-1363
US

V. Phone/Fax

Practice location:
  • Phone: 651-401-5010
  • Fax: 612-235-6447
Mailing address:
  • Phone: 651-401-5010
  • Fax: 612-235-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2382
License Number StateMN

VIII. Authorized Official

Name: AMANDA HOLMBERG
Title or Position: OWNER
Credential: LMFT
Phone: 763-607-8035