Provider Demographics
NPI:1326679978
Name:IGNITE CHILD DEVELOPMENTAL SERVICES P.A.
Entity Type:Organization
Organization Name:IGNITE CHILD DEVELOPMENTAL SERVICES P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:651-271-7929
Mailing Address - Street 1:43 CUNNINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OAKS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-4300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2448 18TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4006
Practice Address - Country:US
Practice Address - Phone:651-271-7929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)