Healthcare Provider Details

I. General information

NPI: 1770728230
Provider Name (Legal Business Name): MN INTEGRATIVE PSYCHOLOGY AND PSYCHIATRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 WILLOW ST SUITE 400
MINNEAPOLIS MN
55403-2269
US

IV. Provider business mailing address

1409 WILLOW ST SUITE 400
MINNEAPOLIS MN
55403-2269
US

V. Phone/Fax

Practice location:
  • Phone: 612-872-1500
  • Fax: 612-872-2205
Mailing address:
  • Phone: 612-872-1500
  • Fax: 612-872-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SILVIA DIVINETZ ROMERO
Title or Position: CEO
Credential: M.D.
Phone: 612-872-1500