Healthcare Provider Details

I. General information

NPI: 1386196673
Provider Name (Legal Business Name): LOUD BODY SOUND MIND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 SELBY AVE STE 101
SAINT PAUL MN
55104-6533
US

IV. Provider business mailing address

1025 SELBY AVE STE 101
SAINT PAUL MN
55104-6533
US

V. Phone/Fax

Practice location:
  • Phone: 651-428-2058
  • Fax:
Mailing address:
  • Phone: 651-428-2058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number17540
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number17540
License Number StateMN

VIII. Authorized Official

Name: MELISSA CAROLINE DUNCAN
Title or Position: PSYCHOTHERAPIST/BUSINESS OWNER
Credential: LICSW
Phone: 651-428-2058