Provider Demographics
NPI:1629108410
Name:LACUNA FOR INTEGRATIVE THERAPIES
Entity Type:Organization
Organization Name:LACUNA FOR INTEGRATIVE THERAPIES
Other - Org Name:JOSHUA M KENT, LICSW
Other - Org Type:Other Name
Authorized Official - Title/Position:LICSW
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-264-0260
Mailing Address - Street 1:5009 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 134
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:612-360-5685
Mailing Address - Fax:952-285-4103
Practice Address - Street 1:5009 EXCELSIOR BLVD
Practice Address - Street 2:SUITE 134
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:612-360-5685
Practice Address - Fax:952-285-4103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15118103TB0200X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN607649100Medicaid
MN800001742Medicare PIN