MEDICARE: FISHBONE 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	101YP2500X	Professional Counselor	C00880	MN

General Provider Information

NPI Number	:	1730557521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FISHBONE LLC

Provider Business Mailing Address
First Line	:	6975 MEADOW CT
Second Line	:
City	:	CENTERVILLE
State	:	MN
Zip	:	55038-8784
Country	:	US
Telephone Number	:	763-220-2213
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 LEXINGTON AVE N
Second Line	:	SUITE C
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-5867
Country	:	US
Telephone Number	:	763-220-2213
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANDREA VEECH
Credential	:	LPCC
Telephone Number	:	763-220-2213

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/10/2015

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Directions to “FISHBONE LLC ” Practice Location

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