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General NPI Number Information
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NPI Number | 1649281676
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Entity Type | Organization
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Legal Business Name | PATHWAYS PSYCHOLOGY ON GRAND, PLLC
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Dates
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Enumeration Date | 08/11/2006
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Last Update Date | 11/21/2008
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Provider Practice Location Address
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Address Line | 1053 GRAND AVE SUITE 116
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City | SAINT PAUL
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State | MN
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Zip | 55105-3022
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Country | US
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Telephone | 651-287-0931
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Fax | 651-287-0967
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Provider Business Mailing Address
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Address Line | 1053 GRAND AVE SUITE 116
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City | SAINT PAUL
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State | MN
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Zip | 55105-3022
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Country | US
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Telephone | 651-287-0931
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Fax | 651-287-0967
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Authorized Official
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Title or Position | HIPAA OFFICER
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Name | DR. JILL R LEBLOND
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Credential | PSYD, LP
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Telephone | 651-287-0931
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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