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11292 86th Ave N Ste 106 Maple Grove MN 55369-4510 | |
| (952) 300-5908 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 11292 86th Ave N Ste 106, Maple Grove, Minnesota |
| Authorized Official Name and Position | Kristine Doten (OWNER) |
| Authorized Official Contact | 9523005908 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
11292 86th Ave N Ste 106 Maple Grove MN 55369-4510 Ph: (952) 300-5908 | 11292 86th Ave N Ste 106 Maple Grove MN 55369-4510 Ph: (952) 300-5908 |
| NPI Number | 1699202952 |
|---|---|
| Provider Enumeration Date | 05/17/2017 |
| Last Update Date | 07/21/2022 |
| Medicare PECOS PAC ID | 3971044124 |
|---|---|
| Medicare Enrollment ID | O20240916002453 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699202952 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | CC01429 (Minnesota) | Primary |
| Provider Name | Carol Ann Dobson |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1831611979 PECOS PAC ID: 6800247024 Enrollment ID: I20240111002470 |
| Provider Name | Madeline Baker Johnson |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1457969057 PECOS PAC ID: 8224479928 Enrollment ID: I20240513002078 |
| Provider Name | Kristine Doten |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1700284452 PECOS PAC ID: 7214478478 Enrollment ID: I20240917001165 |
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