Provider Demographics
NPI:1992469290
Name:MEDORA MENTAL HEALTH AND CONSULTING, PLLC
Entity Type:Organization
Organization Name:MEDORA MENTAL HEALTH AND CONSULTING, PLLC
Other - Org Name:MEDORA MENTAL HEALTH AND CONSULTING
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-968-0227
Mailing Address - Street 1:3613 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2528
Mailing Address - Country:US
Mailing Address - Phone:773-968-0227
Mailing Address - Fax:
Practice Address - Street 1:6 E 45TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-5026
Practice Address - Country:US
Practice Address - Phone:773-968-0227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-24
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty