MEDICARE: MINNESOTA EVIDENCE-BASED THERAPY & ASSESSMENT CLINIC, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1487047346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA EVIDENCE-BASED THERAPY & ASSESSMENT CLINIC, LLC

Provider Business Mailing Address
First Line	:	5413 NICOLLET AVE S
Second Line	:	#164
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1927
Country	:	US
Telephone Number	:	612-308-2508
Fax Number	:	612-486-9497

Provider Business Practice Location Address
First Line	:	5413 NICOLLET AVE S
Second Line	:	#164
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1927
Country	:	US
Telephone Number	:	612-308-2508
Fax Number	:	612-486-9497

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	JACQUELINE WRIGHT
Credential	:	LICSW
Telephone Number	:	612-308-2508

Provider Enumeration Date	:	03/16/2015
Last Update Date	:	06/03/2024

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