MEDICARE: NORTH STAR MENTAL HEALTH, 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	103TC0700X	Clinical Psychologist	5506	MN

General Provider Information

NPI Number	:	1316286974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH STAR MENTAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	2984 RICE ST
Second Line	:
City	:	LITTLE CANADA
State	:	MN
Zip	:	55113-2230
Country	:	US
Telephone Number	:	651-314-4350
Fax Number	:

Provider Business Practice Location Address
First Line	:	2984 RICE ST
Second Line	:
City	:	LITTLE CANADA
State	:	MN
Zip	:	55113-2230
Country	:	US
Telephone Number	:	651-314-4350
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	CARLO A. GIACOMONI
Credential	:	PSYD
Telephone Number	:	763-232-8901

Provider Enumeration Date	:	02/01/2013
Last Update Date	:	03/04/2016

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