=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124384854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2012
-----------------------------------------------------
Last Update Date | 02/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 871 JEFFERSON AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-456-8912
-----------------------------------------------------
Fax | 855-407-1613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 871 JEFFERSON AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 514-568-9126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JEFFREY RAICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-456-8912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 18483
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------