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General NPI Number Information
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NPI Number | 1881753564
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Entity Type | Organization
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Legal Business Name | MEDICINE LAKE CONSULTATION GROUP,PLLC
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Dates
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Enumeration Date | 12/08/2006
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Last Update Date | 01/23/2015
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Provider Practice Location Address
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Address Line | 1155 FORD ROAD UNIT B
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City | ST LOUIS PARK
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State | MN
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Zip | 55426
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Country | US
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Telephone | 952-378-1800
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Fax | 952-378-1714
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Provider Business Mailing Address
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Address Line | 1155 FORD ROAD UNIT B
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City | ST LOUIS PARK
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State | MN
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Zip | 55426
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Country | US
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Telephone | 952-378-1800
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Fax | 952-378-1714
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. ANI C RAM
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Credential |
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Telephone | 952-378-1800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 103TC0700X
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 2084P0800X
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License Number State |
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