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General NPI Number Information
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NPI Number | 1477307890
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Entity Type | Organization
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Legal Business Name | VIRTA THERAPY COLLECTIVE LLC
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Dates
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Enumeration Date | 04/12/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 209 SNELLING AVE N
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City | SAINT PAUL
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State | MN
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Zip | 55104-6326
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Country | US
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Telephone | 507-850-0377
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Fax |
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Provider Business Mailing Address
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Address Line | 209 SNELLING AVE N
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City | SAINT PAUL
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State | MN
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Zip | 55104-6326
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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/THERAPIST
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Name | CAITLIN THARALDSON
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Credential | LICSW
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Telephone | 651-442-1685
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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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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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