=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255528329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDSDOTTER CHARLOTTA CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2007
-----------------------------------------------------
Last Update Date | 10/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2406 GLENWOOD AVE
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55405-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-377-1701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2406 GLENWOOD AVE
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55405-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-377-1701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PSYCHOTHERAPIST
-----------------------------------------------------
Name | CHARLOTTE JEAN IPSEN
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 612-377-1701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LICSW 2075
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------