Healthcare Provider Details

I. General information

NPI: 1063226330
Provider Name (Legal Business Name): MIDNIGHT AND MOONLIGHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3441 CEDAR AVE S
MINNEAPOLIS MN
55407-2336
US

IV. Provider business mailing address

3441 CEDAR AVE S
MINNEAPOLIS MN
55407-2336
US

V. Phone/Fax

Practice location:
  • Phone: 612-913-7111
  • Fax:
Mailing address:
  • Phone: 612-913-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE M ERO-PHILLIPS
Title or Position: OCCUPATIONAL THERAPIST
Credential: MAOT, OTR/L
Phone: 320-266-4304