Provider Demographics
NPI:1457825051
Name:COXALLAH ENRICHMENT SERVICES, LLC
Entity Type:Organization
Organization Name:COXALLAH ENRICHMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DASHERLINE
Authorized Official - Middle Name:COX
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-434-9186
Mailing Address - Street 1:6043 HUDSON RD STE 355
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1017
Mailing Address - Country:US
Mailing Address - Phone:651-434-9186
Mailing Address - Fax:
Practice Address - Street 1:6043 HUDSON RD STE 355
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1017
Practice Address - Country:US
Practice Address - Phone:651-434-9186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty