Provider Demographics
NPI:1184273666
Name:INTROSPECT MENTAL HEALTH LLC
Entity type:Organization
Organization Name:INTROSPECT MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:YERKS
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW LADC
Authorized Official - Phone:651-271-8970
Mailing Address - Street 1:22130 TYPO CREEK DR NE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-4602
Mailing Address - Country:US
Mailing Address - Phone:651-271-8970
Mailing Address - Fax:
Practice Address - Street 1:4801 HIGHWAY 61 N STE 204
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LK
Practice Address - State:MN
Practice Address - Zip Code:55110-2752
Practice Address - Country:US
Practice Address - Phone:763-465-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-08
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty