=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720828387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NALU THERAPY, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2024
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 LAKESHORE DR
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55092-9748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-234-2605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 LAKESHORE DR
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55092-9748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-234-2605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND THERAPIST
-----------------------------------------------------
Name | JESSICA SZMANDA
-----------------------------------------------------
Credential | MA, LPCC, LADC
-----------------------------------------------------
Telephone | 612-201-2591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------