=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609153378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUO PSYCHOTHERAPY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2011
-----------------------------------------------------
Last Update Date | 11/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 RAYMOND AVE STE 230C
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55114-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-695-0174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 RAYMOND AVE STE 230C
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55114-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | MAHINDER KAUR
-----------------------------------------------------
Credential | PSY D, LP
-----------------------------------------------------
Telephone | 612-695-0174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | LP4820
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------