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General NPI Number Information
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NPI Number | 1376384370
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Entity Type | Organization
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Legal Business Name | MIDWEST MINDS ASSESSMENT AND THERAPY, PLLC
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Dates
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Enumeration Date | 06/04/2024
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 1937 WOODLANE DR STE 101
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City | WOODBURY
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State | MN
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Zip | 55125-4043
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Country | US
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Telephone | 651-764-8480
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Fax |
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Provider Business Mailing Address
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Address Line | 1937 WOODLANE DR STE 101
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City | WOODBURY
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State | MN
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Zip | 55125-4043
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Country | US
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Telephone | 651-764-8480
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Fax |
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Authorized Official
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Title or Position | NEUROPSYCHOLOGIST/OWNER
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Name | DR. LISA NIPPOOLDT-BACA
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Credential | PSYD, LP, ABPP
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Telephone | 651-283-0639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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