Healthcare Provider Details

I. General information

NPI: 1487065660
Provider Name (Legal Business Name): TWIN CITIES PSYCHOLOGICAL SERVICES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL SUITE 1455
MINNEAPOLIS MN
55402-2606
US

IV. Provider business mailing address

825 NICOLLET MALL STE 1455
MINNEAPOLIS MN
55402-2703
US

V. Phone/Fax

Practice location:
  • Phone: 612-345-5194
  • Fax:
Mailing address:
  • Phone: 612-345-5194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLP5726
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLP5724
License Number StateMN

VIII. Authorized Official

Name: DR. GRACE KIM
Title or Position: VICE PRESIDENT/PSYCHOLOGIST
Credential: PH.D.
Phone: 612-345-5194