Provider Demographics
NPI:1447236609
Name:AUTISM SOCIETY OF MINNESOTA
Entity Type:Organization
Organization Name:AUTISM SOCIETY OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-647-1083
Mailing Address - Street 1:2380 WYCLIFF ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1279
Mailing Address - Country:US
Mailing Address - Phone:651-647-1083
Mailing Address - Fax:
Practice Address - Street 1:2380 WYCLIFF ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1279
Practice Address - Country:US
Practice Address - Phone:651-647-1083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN323J8AUOtherBLUE CROSS BLUE SHIELD
MN323J8AUOtherBLUE CROSS BLUE SHIELD