Provider Demographics
NPI:1699038265
Name:MINNESOTA ORGANIZATION ON FETAL ALCOHOL SYNDROME (MOFAS)
Entity Type:Organization
Organization Name:MINNESOTA ORGANIZATION ON FETAL ALCOHOL SYNDROME (MOFAS)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MESSELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-917-2370
Mailing Address - Street 1:1811 WEIR DR STE 190
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2292
Mailing Address - Country:US
Mailing Address - Phone:651-738-8561
Mailing Address - Fax:651-730-6657
Practice Address - Street 1:2233 UNIVERSITY AVE W STE 395
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1600
Practice Address - Country:US
Practice Address - Phone:651-917-2370
Practice Address - Fax:651-917-2405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5419103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty