Provider Demographics
NPI:1598150930
Name:NOVA BHS
Entity Type:Organization
Organization Name:NOVA BHS
Other - Org Name:MARYANNE LASSEGARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LASSEGARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-306-4721
Mailing Address - Street 1:3340 INTERLACHEN DR.
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304
Mailing Address - Country:US
Mailing Address - Phone:612-306-4721
Mailing Address - Fax:763-434-6570
Practice Address - Street 1:521 TANGLEWOOD DR.
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126
Practice Address - Country:US
Practice Address - Phone:612-306-4721
Practice Address - Fax:763-434-6570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2187103TB0200X, 103TC0700X, 103TH0100X, 103TP2701X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty