=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609102870
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL MICHAEL NOVOTNY MA, LPCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2009
-----------------------------------------------------
Last Update Date | 10/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 UNIVERSITY AVE W STE 6
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-3453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-636-8677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1375 DAVERN STREET #319
-----------------------------------------------------
City | ST. PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-710-9297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CC00065
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------