Healthcare Provider Details

I. General information

NPI: 1356453211
Provider Name (Legal Business Name): CROSSTOWN COUNSELING, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5939 PORTLAND AVE
MINNEAPOLIS MN
55417-3127
US

IV. Provider business mailing address

5939 PORTLAND AVE
MINNEAPOLIS MN
55417-3127
US

V. Phone/Fax

Practice location:
  • Phone: 612-866-6100
  • Fax: 612-866-9379
Mailing address:
  • Phone: 612-866-6100
  • Fax: 612-866-9379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARK W SMITH
Title or Position: OWNER
Credential: LICSW
Phone: 612-866-6100