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General NPI Number Information
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NPI Number | 1255805800
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Entity Type | Organization
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Legal Business Name | TWIN CITIES TEEN COUNSELING LLC
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Dates
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Enumeration Date | 01/16/2019
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Last Update Date | 01/16/2019
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Provider Practice Location Address
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Address Line | 2375 UNIVERSITY AVE W STE 160
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City | SAINT PAUL
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State | MN
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Zip | 55114-1632
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Country | US
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Telephone | 612-548-4948
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Fax |
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Provider Business Mailing Address
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Address Line | 2618 N 4TH ST
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City | MINNEAPOLIS
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State | MN
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Zip | 55411-2159
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER KORTGARD
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Credential | LICSW
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Telephone | 612-548-4948
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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 |
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License Number State |
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