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General NPI Number Information
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NPI Number | 1194101212
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Entity Type | Organization
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Legal Business Name | AUTISM FAMILY THERAPY INC
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Dates
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Enumeration Date | 07/31/2015
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Last Update Date | 07/31/2015
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Provider Practice Location Address
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Address Line | 12805 HIGHWAY 55 SUITE 402
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City | PLYMOUTH
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State | MN
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Zip | 55441-3859
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Country | US
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Telephone | 612-597-0459
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Fax |
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Provider Business Mailing Address
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Address Line | 6080 IVES LN N
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City | PLYMOUTH
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State | MN
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Zip | 55442-1241
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Country | US
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Telephone | 612-597-0459
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. TAMARA FAYE PHILLIPS
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Credential | MA, LMFT
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Telephone | 612-597-0459
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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 | 2491
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License Number State | MN
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