Provider Demographics
NPI:1275723777
Name:PARKDALE THERAPY GROUP, LLC
Entity Type:Organization
Organization Name:PARKDALE THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:JANKORD
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:952-224-0399
Mailing Address - Street 1:1000 SHELARD PKWY STE 520
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1053
Mailing Address - Country:US
Mailing Address - Phone:952-224-0399
Mailing Address - Fax:952-224-0396
Practice Address - Street 1:1000 SHELARD PKWY STE 520
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1053
Practice Address - Country:US
Practice Address - Phone:952-224-0399
Practice Address - Fax:952-224-0396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301574101YA0400X
MN00054101YP2500X
MN27774103TP0016X
MN1044106H00000X
MN1023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty