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General NPI Number Information
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NPI Number | 1073903886
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Entity Type | Organization
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Legal Business Name | STEPHANIE UNTIEDT, PHD, LLC
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Dates
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Enumeration Date | 02/01/2015
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Last Update Date | 02/01/2015
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Provider Practice Location Address
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Address Line | 5101 OLSON MEMORIAL HWY STE 4007
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City | GOLDEN VALLEY
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State | MN
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Zip | 55422-5164
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Country | US
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Telephone | 763-595-7294
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Fax | 763-595-7293
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Provider Business Mailing Address
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Address Line | 5101 OLSON MEMORIAL HWY STE 4007
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City | GOLDEN VALLEY
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State | MN
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Zip | 55422-5164
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Country | US
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Telephone | 763-595-7294
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Fax | 763-595-7293
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Authorized Official
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Title or Position | PSCYHOLOGIST
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Name | DR. STEPHANIE ANN UNTIEDT
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Credential | PHD
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Telephone | 763-595-7294
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 4599
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License Number State | MN
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