Provider Demographics
NPI:1629390125
Name:FAMILY LIFESTYLES, COUNSELING & THERAPY
Entity Type:Organization
Organization Name:FAMILY LIFESTYLES, COUNSELING & THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:BLONIGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LP
Authorized Official - Phone:612-716-7159
Mailing Address - Street 1:5100 THIMSEN AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4108
Mailing Address - Country:US
Mailing Address - Phone:612-716-7159
Mailing Address - Fax:952-474-4025
Practice Address - Street 1:5100 THIMSEN AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4108
Practice Address - Country:US
Practice Address - Phone:612-716-7159
Practice Address - Fax:952-474-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty