MEDICARE: PAULA JOY DETJEN LMFT

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	1399	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11-3791736-001	OTHER	MN	AMERICA'S PPO

General Provider Information

NPI Number	:	1578585527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA JOY DETJEN LMFT

Provider Business Mailing Address
First Line	:	1000 SUPERIOR DR
Second Line	:
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-4873
Country	:	US
Telephone Number	:	507-581-0430
Fax Number	:

Provider Business Practice Location Address
First Line	:	706 DIVISION ST S
Second Line	:
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-2427
Country	:	US
Telephone Number	:	507-581-0430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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