=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992305973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TELEPSYCHUS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2020
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8518 SOUTH MAPLEBROOK CIRCLE
-----------------------------------------------------
City | BROOKLYN PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-462-5121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275 4TH ST E STE 807
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55101-1687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-462-5121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KAU MACADOR QUEEGLAY
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 612-462-5121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------