=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881568152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONDER HEALTH PEDIATRIC CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2025
-----------------------------------------------------
Last Update Date | 09/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7825 WASHINGTON AVE S STE 615C
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-417-6115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7825 WASHINGTON AVE S STE 615C
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | QUALIFIED SUPERVISING PROFESSIONAL
-----------------------------------------------------
Name | CRISSY JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-417-6115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------