=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295979664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TWIN CITIES BEHAVIORAL HEALTH, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2009
-----------------------------------------------------
Last Update Date | 04/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7300 METRO BLVD SUITE 635
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-831-3662
-----------------------------------------------------
Fax | 952-831-3559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7300 METRO BLVD SUITE 635
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-831-3662
-----------------------------------------------------
Fax | 952-831-3559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OFFICER
-----------------------------------------------------
Name | DR. JOSEPH I SHAGALOW
-----------------------------------------------------
Credential | PSYD LP
-----------------------------------------------------
Telephone | 952-831-3662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | LP4413
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------