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General NPI Number Information
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NPI Number | 1194184465
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Entity Type | Organization
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Legal Business Name | CHJL LLC
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Dates
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Enumeration Date | 02/16/2016
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Last Update Date | 02/16/2016
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Provider Practice Location Address
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Address Line | 8120 PENN AVE S STE 252
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City | BLOOMINGTON
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State | MN
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Zip | 55431-1358
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Country | US
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Telephone | 612-251-4753
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Fax | 651-730-6657
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Provider Business Mailing Address
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Address Line | 8120 PENN AVE S STE. 252
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City | BLOOMINGTON
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State | MN
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Zip | 55437
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Country | US
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Telephone | 612-251-4753
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Fax | 651-730-6657
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Authorized Official
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Title or Position | PSYCHOTHERAPIST/PARTNER
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Name | MS. LOUISE PHELPS PAGE
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Credential | LPCC
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Telephone | 612-251-4753
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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 | 4714
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | CC00282
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License Number State | MN
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