Healthcare Provider Details

I. General information

NPI: 1043512593
Provider Name (Legal Business Name): PRAIRIE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7616 CURRELL BLVD
WOODBURY MN
55125-2290
US

IV. Provider business mailing address

7616 CURRELL BLVD STE 100
WOODBURY MN
55125-2295
US

V. Phone/Fax

Practice location:
  • Phone: 651-259-9700
  • Fax: 651-259-9730
Mailing address:
  • Phone: 651-259-9700
  • Fax: 651-259-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT 1541
License Number StateMN

VIII. Authorized Official

Name: SIMA DERAKHSHANI SEAVER
Title or Position: THERAPIST
Credential: LMFT
Phone: 651-259-9700