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General NPI Number Information
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NPI Number | 1629108410
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Entity Type | Organization
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Legal Business Name | LACUNA FOR INTEGRATIVE THERAPIES
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 08/28/2008
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Provider Practice Location Address
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Address Line | 5009 EXCELSIOR BLVD SUITE 134
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City | ST. LOUIS PARK
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State | MN
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Zip | 55416
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Country | US
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Telephone | 612-360-5685
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Fax | 952-285-4103
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Provider Business Mailing Address
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Address Line | 5009 EXCELSIOR BLVD SUITE 134
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City | ST. LOUIS PARK
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State | MN
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Zip | 55416
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Country | US
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Telephone | 612-360-5685
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Fax | 952-285-4103
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Authorized Official
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Title or Position | LICSW
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Name | JOSHUA M KENT
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Credential |
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Telephone | 651-264-0260
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 15118
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number | 15118
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License Number State | MN
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