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7115 Forthun Rd Ste 105 Baxter MN 56425-8598 | |
| (704) 506-6267 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Psychologist |
| Location | 7115 Forthun Rd Ste 105, Baxter, Minnesota |
| Authorized Official Name and Position | Leslie Johnson (CEO) |
| Authorized Official Contact | 7045066267 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
11000 Optum Cir Eden Prairie MN 55344-2503 Ph: (704) 506-6267 | 7115 Forthun Rd Ste 105 Baxter MN 56425-8598 Ph: (704) 506-6267 |
| NPI Number | 1124898556 |
|---|---|
| Provider Enumeration Date | 01/05/2024 |
| Last Update Date | 04/24/2024 |
| Certification Date | 04/24/2024 |
| Medicare PECOS PAC ID | 0941648463 |
|---|---|
| Medicare Enrollment ID | O20240725003342 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124898556 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
| Provider Name | David C Anderholm |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1528039682 PECOS PAC ID: 4880623206 Enrollment ID: I20050805000741 |
| Provider Name | Jeanne M Kurtz |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1760544423 PECOS PAC ID: 9133133168 Enrollment ID: I20060130000486 |
| Provider Name | Melissa A Virnig |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1558379974 PECOS PAC ID: 3375549652 Enrollment ID: I20061030000485 |
| Provider Name | Sara J Prescher |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1669608246 PECOS PAC ID: 7214242189 Enrollment ID: I20150820012296 |
| Provider Name | Jessica Eastman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1780274563 PECOS PAC ID: 6406262591 Enrollment ID: I20210316001152 |
| Provider Name | Nicolle Hagen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1477038560 PECOS PAC ID: 4183095458 Enrollment ID: I20230124002154 |
| Provider Name | Jenifer Diane Emmrich Budnick |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1033676580 PECOS PAC ID: 8820432024 Enrollment ID: I20240215002089 |
| Provider Name | Madeline A Metz |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1043915549 PECOS PAC ID: 8325484058 Enrollment ID: I20240315002063 |
| Provider Name | Beth Marie Bechtold |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1255178117 PECOS PAC ID: 0345780672 Enrollment ID: I20240912002592 |
| Provider Name | Caleb Anderson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1518673862 PECOS PAC ID: 0749713022 Enrollment ID: I20241024002882 |
| Provider Name | Alexandra Nicole Brown |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1518540301 PECOS PAC ID: 2163956863 Enrollment ID: I20241115003733 |
| Provider Name | Amy Perry |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1144005596 PECOS PAC ID: 4183159536 Enrollment ID: I20241122001251 |
| Provider Name | Ashley Mae Leboeuf |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1962149567 PECOS PAC ID: 4587190350 Enrollment ID: I20241204002134 |
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