=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144694407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPEN PATH THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2015
-----------------------------------------------------
Last Update Date | 01/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4590 SCOTT TRL SUITE 200
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-548-1232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 537 TUTTLE CT
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55033-8822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-315-4613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | MARLENA SAUER
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 651-315-4613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 2829
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------