Healthcare Provider Details

I. General information

NPI: 1184240103
Provider Name (Legal Business Name): ADHD&U
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2196 CARTER AVE
SAINT PAUL MN
55108-1709
US

IV. Provider business mailing address

2196 CARTER AVE
SAINT PAUL MN
55108-1709
US

V. Phone/Fax

Practice location:
  • Phone: 651-675-6273
  • Fax:
Mailing address:
  • Phone: 651-675-6273
  • 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 Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE QUIE
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PHD, L.P.
Phone: 651-675-6273