Healthcare Provider Details

I. General information

NPI: 1184273666
Provider Name (Legal Business Name): INTROSPECT MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2019
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 HIGHWAY 61 N STE 204
WHITE BEAR LK MN
55110-2752
US

IV. Provider business mailing address

22130 TYPO CREEK DR NE
WYOMING MN
55092-4602
US

V. Phone/Fax

Practice location:
  • Phone: 763-465-6700
  • Fax:
Mailing address:
  • Phone: 651-271-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA YERKS
Title or Position: OWNER
Credential: LICSW LADC
Phone: 651-271-8970