MEDICARE: HYPERINTELLIGENT STOAT 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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1568267151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYPERINTELLIGENT STOAT LLC

Provider Business Mailing Address
First Line	:	4528 MADISON ST NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-2363
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	711 W LAKE ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3357
Country	:	US
Telephone Number	:	612-314-9542
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEONG EUN PARK
Credential	:	LMFT
Telephone Number	:	612-314-9542

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	02/17/2025

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