Provider Demographics
NPI:1588818769
Name:CHASKA COUNSELING AND GUIDANCE, LLC
Entity Type:Organization
Organization Name:CHASKA COUNSELING AND GUIDANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KNUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:952-484-3509
Mailing Address - Street 1:562 BAVARIA LN
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-4597
Mailing Address - Country:US
Mailing Address - Phone:952-484-3509
Mailing Address - Fax:952-361-0145
Practice Address - Street 1:562 BAVARIA LN
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-4597
Practice Address - Country:US
Practice Address - Phone:952-484-3509
Practice Address - Fax:952-361-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10527251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4138228110Medicaid