Healthcare Provider Details

I. General information

NPI: 1376384370
Provider Name (Legal Business Name): MIDWEST MINDS ASSESSMENT AND THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1937 WOODLANE DR STE 101
WOODBURY MN
55125-4043
US

IV. Provider business mailing address

1937 WOODLANE DR STE 101
WOODBURY MN
55125-4043
US

V. Phone/Fax

Practice location:
  • Phone: 651-764-8480
  • Fax:
Mailing address:
  • Phone: 651-764-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LISA NIPPOOLDT-BACA
Title or Position: NEUROPSYCHOLOGIST/OWNER
Credential: PSYD, LP, ABPP
Phone: 651-283-0639