Provider Demographics
NPI:1578316162
Name:NORTHSTAR WELLNESS LLC
Entity Type:Organization
Organization Name:NORTHSTAR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GLIDDON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-990-2383
Mailing Address - Street 1:4758 PARK DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8577
Mailing Address - Country:US
Mailing Address - Phone:612-990-2383
Mailing Address - Fax:
Practice Address - Street 1:4758 PARK DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8577
Practice Address - Country:US
Practice Address - Phone:612-990-2383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty