MEDICARE: CASPERSEN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	12770	MN

General Provider Information

NPI Number	:	1225326036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASPERSEN, LLC

Provider Business Mailing Address
First Line	:	4284 DAHLBERG DR
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4805
Country	:	US
Telephone Number	:	952-428-6332
Fax Number	:	952-562-2827

Provider Business Practice Location Address
First Line	:	4284 DAHLBERG DR
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4805
Country	:	US
Telephone Number	:	952-428-6332
Fax Number	:	952-562-2827

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOHN R. STILLMAN
Credential	:	LICSW
Telephone Number	:	612-558-2705

Provider Enumeration Date	:	07/13/2011
Last Update Date	:	07/13/2021

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