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General NPI Number Information
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NPI Number | 1477829935
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Entity Type | Organization
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Legal Business Name | SOARING EAGLE THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 03/29/2012
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Last Update Date | 03/29/2012
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Provider Practice Location Address
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Address Line | 2046 SAINT CLAIR AVE
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City | SAINT PAUL
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State | MN
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Zip | 55105-1650
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Country | US
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Telephone | 651-269-0485
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Fax |
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Provider Business Mailing Address
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Address Line | 1775 JULIET AVE
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City | SAINT PAUL
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State | MN
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Zip | 55105-2124
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Country | US
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Telephone | 651-269-0485
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MR. JAY RUSSELL HUNTER
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Credential | MA, LMFT
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Telephone | 651-269-0485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1605
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License Number State | MN
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