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NPI Code Detail

MEDICARE: CGC LLC

MEDICARE: CGC 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
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11336374750OTHERMNCLINICAL SOCIAL WORKER
21447644224OTHERMNSOCIAL WORKER CLINICAL

General Provider Information

NPI Number : 1699239566
Entity Type Code : Organization
Provider Name (Legal Business Name) : CGC LLC
Provider Business Mailing Address
First Line : 4208 PARK GLEN RD
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55416-4758
Country : US
Telephone Number : 630-677-5437
Fax Number :
Provider Business Practice Location Address
First Line : 4208 PARK GLEN RD
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55416-4758
Country : US
Telephone Number : 630-677-5437
Fax Number :
Authorized Official
Title or Position : CLINICAL PSYCHOLOGIST
Name : DR. ELIZABETH VOGT
Credential : LP
Telephone Number : 612-642-1754
Provider Enumeration Date : 01/24/2019
Last Update Date : 11/07/2024

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