Provider Demographics
NPI:1861867251
Name:PSYCHOTHERAPY AND RESILIENCE, PLLC
Entity Type:Organization
Organization Name:PSYCHOTHERAPY AND RESILIENCE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HELENA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:MACKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-345-0598
Mailing Address - Street 1:366 SELBY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1880
Mailing Address - Country:US
Mailing Address - Phone:612-345-0598
Mailing Address - Fax:
Practice Address - Street 1:366 SELBY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1880
Practice Address - Country:US
Practice Address - Phone:612-345-0598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4407103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN074982600Medicaid
MN074982600Medicaid