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General NPI Number Information
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NPI Number | 1093061301
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Entity Type | Organization
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Legal Business Name | THE MINNESOTA CENTER FOR COUPLES AND FAMILY THERAPY, LLC
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Dates
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Enumeration Date | 07/24/2012
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Last Update Date | 07/24/2012
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Provider Practice Location Address
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Address Line | 1120 E 80TH ST SUITE 200
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City | BLOOMINGTON
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State | MN
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Zip | 55420-1462
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Country | US
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Telephone | 952-767-0442
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Fax |
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Provider Business Mailing Address
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Address Line | 1120 E 80TH ST SUITE 200
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City | BLOOMINGTON
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State | MN
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Zip | 55420-1462
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Country | US
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Telephone | 952-767-0442
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. ROGER A BALLOU
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Credential | PHD, LMFT
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Telephone | 651-246-7592
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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