| |
10650 County Road 81 Ste 133 Maple Grove MN 55369-4020 | |
(763) 445-9801 | |
Not Available |
Full Name | |
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Speciality | Marriage & Family Therapist |
Location | 10650 County Road 81 Ste 133, Maple Grove, Minnesota |
Authorized Official Name and Position | Christine Isabel Pena (OWNER/MENTAL HEALTH PROFESSIONAL) |
Authorized Official Contact | 7634459801 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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7808 Noid Dr Brooklyn Park MN 55428-2206 Ph: () - | 10650 County Road 81 Ste 133 Maple Grove MN 55369-4020 Ph: (763) 445-9801 |
NPI Number | 1679357826 |
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Provider Enumeration Date | 08/21/2023 |
Last Update Date | 04/16/2024 |
Certification Date | 04/16/2024 |
Medicare PECOS PAC ID | 0446792063 |
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Medicare Enrollment ID | O20240610003712 |
Identifier | Type | State | Issuer |
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1679357826 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
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106H00000X | Marriage & Family Therapist | (* (Not Available)) | Primary |
Provider Name | Christine Isabel Pena |
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Provider Type | Practitioner - Marriage And Family Therapist |
Provider Identifiers | NPI Number: 1548620941 PECOS PAC ID: 0446698146 Enrollment ID: I20240610003748 |
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