MEDICARE: PORTLIGHT MENTAL HEALTH

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1841776960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTLIGHT MENTAL HEALTH

Provider Business Mailing Address
First Line	:	5413 NICOLLET AVE # 152
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1927
Country	:	US
Telephone Number	:	612-524-8243
Fax Number	:

Provider Business Practice Location Address
First Line	:	5413 NICOLLET AVE # 152
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1927
Country	:	US
Telephone Number	:	612-524-8243
Fax Number	:

Authorized Official
Title or Position	:	LICENSED THERAPIST
Name	:	MICHAEL DALY
Credential	:	MA, LMFT
Telephone Number	:	612-524-8243

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	07/11/2018

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Directions to “PORTLIGHT MENTAL HEALTH ” Practice Location

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