MEDICARE: MINNESOTA BEHAVIORAL SPECIALISTS

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	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932734811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA BEHAVIORAL SPECIALISTS

Provider Business Mailing Address
First Line	:	4635 NICOLS RD # 104
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-3337
Country	:	US
Telephone Number	:	651-900-2110
Fax Number	:

Provider Business Practice Location Address
First Line	:	4635 NICOLS RD # 104
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-3337
Country	:	US
Telephone Number	:	651-900-2110
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SUPERVISOR
Name	:	PAIGE BERLAND
Credential	:	LPCC, BCBA
Telephone Number	:	612-289-6480

Provider Enumeration Date	:	03/11/2020
Last Update Date	:	03/26/2020

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