=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023874211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENAE RUBLE LMFT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2024
-----------------------------------------------------
Last Update Date | 02/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4660 SLATER RD STE 220D
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-4047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-940-2102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7493 147TH ST W STE 107
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55124-7570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DENAE RUBLE
-----------------------------------------------------
Credential | MA LMFT
-----------------------------------------------------
Telephone | 612-940-2102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------