=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942855077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARMAGNE DERICHS MA, LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2019
-----------------------------------------------------
Last Update Date | 08/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6363 FRANCE AVE S STE 200
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-903-1392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7137 CHICAGO AVE APT 7
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55423-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-282-4625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 01574
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------