Healthcare Provider Details

I. General information

NPI: 1710227103
Provider Name (Legal Business Name): PARK AVENUE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 NICOLLET AVE
MINNEAPOLIS MN
55404-3461
US

IV. Provider business mailing address

2430 NICOLLET AVE
MINNEAPOLIS MN
55404-3461
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-7443
  • Fax: 612-871-0194
Mailing address:
  • Phone: 612-871-7443
  • Fax: 612-871-0194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK CASAGRANDE
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A.
Phone: 612-871-7443