=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639574999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOTHERAPY - PSICOTERAPIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2014
-----------------------------------------------------
Last Update Date | 10/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 AMERICAN BLVD E 142
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55420-1392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-214-5170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1981 CROWN POINT DR
-----------------------------------------------------
City | MENDOTA HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55118-4203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-214-5170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MRS. MARIA ANGELICA KELLER
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 651-214-5170
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 16155
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------