Healthcare Provider Details

I. General information

NPI: 1659863173
Provider Name (Legal Business Name): NEW LEAF THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 COUNTY ROAD B2 W STE 240
ROSEVILLE MN
55113-2722
US

IV. Provider business mailing address

62 JUNIPER ST
MAHTOMEDI MN
55115-1502
US

V. Phone/Fax

Practice location:
  • Phone: 203-710-1992
  • Fax:
Mailing address:
  • Phone: 203-710-1992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number24571
License Number StateMN

VIII. Authorized Official

Name: STEPHANIE ROBINSON
Title or Position: PRESIDENT
Credential: LICSW
Phone: 203-710-1992