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General NPI Number Information
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NPI Number | 1104038215
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Entity Type | Organization
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Legal Business Name | CENTER FOR MINDFUL DIALOGUE, PA
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 416 E HENNEPIN AVE SUITE 107
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City | MINNEAPOLIS
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State | MN
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Zip | 55414-1006
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Country | US
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Telephone | 612-379-5360
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Fax | 612-379-5353
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Provider Business Mailing Address
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Address Line | 416 E HENNEPIN AVE SUITE 107
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City | MINNEAPOLIS
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State | MN
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Zip | 55414-1006
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Country | US
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Telephone | 612-379-5360
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Fax | 612-379-5353
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARTHA SUSAN COHEN
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Credential | PH.D.
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Telephone | 612-379-5360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP1749
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License Number State | MN
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