=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578075354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOTH SIDES OF THE RIVER COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 557 7TH ST W STE 204
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-964-0962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 557 7TH ST W STE 204
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-964-0962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | TERESA LARGAESPADA
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 612-423-8231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 2027
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4430
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------