Provider Demographics
NPI:1801376587
Name:EQUILIBRIYA, LLC
Entity Type:Organization
Organization Name:EQUILIBRIYA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LADC, CST
Authorized Official - Phone:651-342-2175
Mailing Address - Street 1:105 NEW ENGLAND PL STE 150
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2036
Mailing Address - Country:US
Mailing Address - Phone:651-342-2175
Mailing Address - Fax:
Practice Address - Street 1:105 NEW ENGLAND PL STE 150
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-2036
Practice Address - Country:US
Practice Address - Phone:651-342-2175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN81101Y00000X
MN3313101Y00000X, 106H00000X
MN303560101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty