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General NPI Number Information
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NPI Number | 1629390125
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Entity Type | Organization
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Legal Business Name | FAMILY LIFESTYLES, COUNSELING & THERAPY
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Dates
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Enumeration Date | 02/24/2010
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Last Update Date | 02/24/2010
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Provider Practice Location Address
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Address Line | 5100 THIMSEN AVE SUITE 130
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City | MINNETONKA
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State | MN
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Zip | 55345-4108
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Country | US
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Telephone | 612-716-7159
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Fax | 952-474-4025
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Provider Business Mailing Address
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Address Line | 5100 THIMSEN AVE SUITE 130
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City | MINNETONKA
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State | MN
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Zip | 55345-4108
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Country | US
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Telephone | 612-716-7159
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Fax | 952-474-4025
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. KEVIN H. BLONIGEN
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Credential | M.A., L.P
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Telephone | 612-716-7159
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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 3981
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License Number State | MN
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