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General NPI Number Information
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NPI Number | 1417204751
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Entity Type | Organization
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Legal Business Name | MINNETONKA PSYCHOLOGY AND WELLNESS
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Dates
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Enumeration Date | 08/06/2012
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Last Update Date | 07/10/2014
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Provider Practice Location Address
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Address Line | 19765 HIGHWAY 7 SUITE 203
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City | SHOREWOOD
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State | MN
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Zip | 55331
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Country | US
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Telephone | 952-767-0442
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Fax | 952-854-1647
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Provider Business Mailing Address
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Address Line | 19765 HIGHWAY 7 SUITE 203
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City | SHOREWOOD
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State | MN
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Zip | 55331
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Country | US
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Telephone | 952-767-0442
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Fax | 952-854-1647
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. ROGER A. BALLOU
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Credential | PHD
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Telephone | 952-767-0442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 1130
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License Number State | MN
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