Provider Demographics
NPI:1417204751
Name:MINNETONKA PSYCHOLOGY AND WELLNESS
Entity Type:Organization
Organization Name:MINNETONKA PSYCHOLOGY AND WELLNESS
Other - Org Name:MINNESOTA RELATIONSHIP CENTER
Other - Org Type:Former Legal Business Name
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
Authorized Official - Phone:952-767-0442
Mailing Address - Street 1:19765 HIGHWAY 7
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SHOREWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55331
Mailing Address - Country:US
Mailing Address - Phone:952-767-0442
Mailing Address - Fax:952-854-1647
Practice Address - Street 1:19765 HIGHWAY 7
Practice Address - Street 2:SUITE 203
Practice Address - City:SHOREWOOD
Practice Address - State:MN
Practice Address - Zip Code:55331
Practice Address - Country:US
Practice Address - Phone:952-767-0442
Practice Address - Fax:952-854-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty