Healthcare Provider Details

I. General information

NPI: 1275279655
Provider Name (Legal Business Name): RIVER CITY THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 LEARNING LN
RED WING MN
55066-4533
US

IV. Provider business mailing address

4911 LEARNING LN
RED WING MN
55066-4533
US

V. Phone/Fax

Practice location:
  • Phone: 651-360-3202
  • Fax: 651-369-2833
Mailing address:
  • Phone: 651-360-3202
  • Fax: 651-369-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KYLIE BALAUN
Title or Position: OWNER & CLINICAL DIRECTOR
Credential: M.S., BCBA
Phone: 651-360-3202