=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336230713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERATIONS: COMMUNITY SUPPORT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 04/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 MARIE AVE E
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55118-5910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-552-9071
-----------------------------------------------------
Fax | 651-552-9874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2649 PARK AVE S.
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-676-1604
-----------------------------------------------------
Fax | 612-379-8235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KATHLEEN JOAN GORMAN
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 612-676-1604
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1500
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------