Healthcare Provider Details

I. General information

NPI: 1457175267
Provider Name (Legal Business Name): THE COMPASSION BOUTIQUE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2024
Last Update Date: 11/09/2024
Certification Date: 11/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PARK GLEN RD STE 450
ST LOUIS PARK MN
55416-5190
US

IV. Provider business mailing address

4500 PARK GLEN RD STE 450
ST LOUIS PARK MN
55416-5190
US

V. Phone/Fax

Practice location:
  • Phone: 952-259-9099
  • Fax:
Mailing address:
  • Phone: 952-259-9099
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. ELIZABETH WAGNER
Title or Position: CEO
Credential: PSYD
Phone: 952-295-9099