Provider Demographics
NPI:1053485904
Name:ATTACHMENT AND FAMILY CENTER OF MINNESOTA
Entity Type:Organization
Organization Name:ATTACHMENT AND FAMILY CENTER OF MINNESOTA
Other - Org Name:FAMILY ATTACHMENT AND COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXESCUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-234-4632
Mailing Address - Street 1:102 N CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1918
Mailing Address - Country:US
Mailing Address - Phone:952-475-2818
Mailing Address - Fax:952-475-3356
Practice Address - Street 1:102 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1918
Practice Address - Country:US
Practice Address - Phone:952-475-2818
Practice Address - Fax:952-475-3356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN118447400Medicaid
MN05142700Medicaid