Provider Demographics
NPI:1578835310
Name:LAKE MINNETONKA COUNSELING
Entity Type:Organization
Organization Name:LAKE MINNETONKA COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW,, LADC, BCC
Authorized Official - Phone:612-386-2311
Mailing Address - Street 1:470 COUNTY ROAD 110 NORTH
Mailing Address - Street 2:
Mailing Address - City:MINNETRISTA
Mailing Address - State:MN
Mailing Address - Zip Code:55364-8315
Mailing Address - Country:US
Mailing Address - Phone:612-386-2311
Mailing Address - Fax:
Practice Address - Street 1:432 MILL ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-8304
Practice Address - Country:US
Practice Address - Phone:612-386-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18016261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health