Provider Demographics
NPI:1750301040
Name:TED LOBBY, LLC
Entity Type:Organization
Organization Name:TED LOBBY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LOBBY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:952-922-0192
Mailing Address - Street 1:6600 FRANCE AVE S
Mailing Address - Street 2:# 472
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1805
Mailing Address - Country:US
Mailing Address - Phone:952-922-0192
Mailing Address - Fax:
Practice Address - Street 1:6600 FRANCE AVE S
Practice Address - Street 2:# 472
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1805
Practice Address - Country:US
Practice Address - Phone:952-922-0192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1145261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN045757400Medicaid
MN800001452Medicare ID - Type UnspecifiedLICSW