Provider Demographics
NPI:1093061301
Name:THE MINNESOTA CENTER FOR COUPLES AND FAMILY THERAPY, LLC
Entity Type:Organization
Organization Name:THE MINNESOTA CENTER FOR COUPLES AND FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:651-246-7592
Mailing Address - Street 1:1120 E 80TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1462
Mailing Address - Country:US
Mailing Address - Phone:952-767-0442
Mailing Address - Fax:
Practice Address - Street 1:1120 E 80TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1462
Practice Address - Country:US
Practice Address - Phone:952-767-0442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty