=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962800169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVELYN NERENBERG
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2014
-----------------------------------------------------
Last Update Date | 12/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5780 LINCOLN DR SUITE 124
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55436-1640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-935-3472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5780 LINCOLN DR SUITE 124
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55436-1640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-935-3472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | JANET M SCHULTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-224-1905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | H01471050090001
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------