Provider Demographics
NPI:1407285372
Name:MOULIKGUPTA, PALLABI
Entity Type:Individual
Prefix:
First Name:PALLABI
Middle Name:
Last Name:MOULIKGUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 BOONE AVE N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2060 CENTRE POINTE BLVD
Practice Address - Street 2:SUITE #3
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55120-1269
Practice Address - Country:US
Practice Address - Phone:651-774-0011
Practice Address - Fax:651-774-0606
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2786106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist