Provider Demographics
NPI:1942310974
Name:ABC MENTAL HEALTH THERAPY
Entity Type:Organization
Organization Name:ABC MENTAL HEALTH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAINE
Authorized Official - Middle Name:QIAO
Authorized Official - Last Name:JORENTO
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-815-5145
Mailing Address - Street 1:1845 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3401
Mailing Address - Country:US
Mailing Address - Phone:651-644-2600
Mailing Address - Fax:651-644-2888
Practice Address - Street 1:1845 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3401
Practice Address - Country:US
Practice Address - Phone:651-644-2600
Practice Address - Fax:651-644-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCERTIFIED DAY TX261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)