Provider Demographics
NPI:1225199953
Name:ANXIETY & DEPRESSION CLINIC OF THE TWIN CITIES, PA
Entity Type:Organization
Organization Name:ANXIETY & DEPRESSION CLINIC OF THE TWIN CITIES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-404-9124
Mailing Address - Street 1:18300 MTKA BLVD., STE 210
Mailing Address - Street 2:
Mailing Address - City:DEEPHAVEN
Mailing Address - State:MN
Mailing Address - Zip Code:55391-3272
Mailing Address - Country:US
Mailing Address - Phone:952-404-9124
Mailing Address - Fax:952-404-9273
Practice Address - Street 1:18300 MTKA BLVD., STE 210
Practice Address - Street 2:
Practice Address - City:DEEPHAVEN
Practice Address - State:MN
Practice Address - Zip Code:55391-3272
Practice Address - Country:US
Practice Address - Phone:952-404-9124
Practice Address - Fax:952-404-9273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN130151041C0700X
MN8292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02989Medicare ID - Type UnspecifiedMDC-GRP