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General NPI Number Information
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NPI Number | 1568585420
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Entity Type | Organization
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Legal Business Name | MIDTOWN MANAGEMENT LTD
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Dates
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Enumeration Date | 04/07/2007
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Last Update Date | 03/24/2023
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Provider Practice Location Address
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Address Line | 2324 UNIVERSITY AVE W, STE 100
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City | ST PAUL
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State | MN
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Zip | 55114-1854
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Country | US
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Telephone | 651-641-1009
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Fax | 651-789-5677
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Provider Business Mailing Address
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Address Line | 2324 UNIVERSITY AVE W, STE 100
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City | ST PAUL
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State | MN
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Zip | 55114-1854
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Country | US
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Telephone | 651-641-1009
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Fax | 651-789-5677
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Authorized Official
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Title or Position | THERAPIST/PARTNER
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Name | JAMES WAGNER
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Credential | LMFT
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Telephone | 651-641-1009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP 2149
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP 3528
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License Number State | MN
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