MEDICARE: SHOREVIEW MENTAL HEALTH CENTER, 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	103T00000X	Psychologist	LP5097	MN

General Provider Information

NPI Number	:	1558735779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOREVIEW MENTAL HEALTH CENTER, LLC

Provider Business Mailing Address
First Line	:	5985 RICE CREEK PKWY STE 201
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-5037
Country	:	US
Telephone Number	:	651-247-8128
Fax Number	:

Provider Business Practice Location Address
First Line	:	5985 RICE CREEK PKWY STE 201
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-5037
Country	:	US
Telephone Number	:	651-348-7240
Fax Number	:	651-348-7265

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JEANETTE BALFE-GROH
Credential	:	LP,PSYD
Telephone Number	:	651-247-8128

Provider Enumeration Date	:	11/27/2015
Last Update Date	:	02/27/2018

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