Healthcare Provider Details

I. General information

NPI: 1376765529
Provider Name (Legal Business Name): CHILD AND FAMILY SPECIALTY CLINIC P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4748 CHICAGO AVE STE 1
MINNEAPOLIS MN
55407-4311
US

IV. Provider business mailing address

4748 CHICAGO AVE STE 1
MINNEAPOLIS MN
55407-4311
US

V. Phone/Fax

Practice location:
  • Phone: 612-821-1920
  • Fax: 612-821-1919
Mailing address:
  • Phone: 952-250-6948
  • Fax: 612-821-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00215
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9839
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15301
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1075
License Number StateMN

VIII. Authorized Official

Name: JEANNE ELLEN GILFIX
Title or Position: CFO
Credential:
Phone: 612-821-1920