Provider Demographics
NPI:1568585420
Name:MIDTOWN MANAGEMENT LTD
Entity Type:Organization
Organization Name:MIDTOWN MANAGEMENT LTD
Other - Org Name:NORTHLAND THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THERAPIST/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:651-641-1009
Mailing Address - Street 1:2324 UNIVERSITY AVE W, STE 100
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1854
Mailing Address - Country:US
Mailing Address - Phone:651-641-1009
Mailing Address - Fax:651-789-5677
Practice Address - Street 1:2324 UNIVERSITY AVE W, STE 100
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1854
Practice Address - Country:US
Practice Address - Phone:651-641-1009
Practice Address - Fax:651-789-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3528103T00000X
MNLP 2149103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN876248100Medicaid
MNC02155Medicare ID - Type Unspecified
MN876248100Medicaid