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General NPI Number Information
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NPI Number | 1861198723
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Entity Type | Organization
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Legal Business Name | EQUILIBRIUM BRAIN BODY BALANCE
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Dates
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Enumeration Date | 02/02/2023
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Last Update Date | 02/02/2023
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Provider Practice Location Address
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Address Line | 12800 WHITEWATER DR SUITE 100- 2016
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City | MINNETONKA
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State | MN
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Zip | 55343
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Country | US
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Telephone | 612-289-3465
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Fax |
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Provider Business Mailing Address
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Address Line | 7730 LAREDO DR UNIT 163
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City | CHANHASSEN
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State | MN
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Zip | 55317-1208
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/PMHNP
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Name | THERESE M HOUNDT-DALBERG
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Credential | CNP, PMHNP
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Telephone | 612-289-2365
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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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