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General NPI Number Information
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NPI Number | 1225588726
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Entity Type | Organization
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Legal Business Name | MIDWAY COUNSELING, LLC
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Dates
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Enumeration Date | 10/07/2016
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Last Update Date | 10/07/2016
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Provider Practice Location Address
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Address Line | 6550 YORK AVE S SUITE 410
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City | EDINA
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State | MN
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Zip | 55435-2347
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Country | US
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Telephone | 612-656-9394
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Fax |
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Provider Business Mailing Address
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Address Line | 3441 35TH AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55406-2740
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Country | US
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Telephone | 612-656-9394
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TAMMY R. TUCKER
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Credential | MA, LPCC
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Telephone | 612-656-9394
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 00925
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License Number State | MN
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