Provider Demographics
NPI:1255943361
Name:INTERGALACTIC THERAPY CENTRE LLC
Entity type:Organization
Organization Name:INTERGALACTIC THERAPY CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARAD
Authorized Official - Middle Name:HAGI
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:612-458-8723
Mailing Address - Street 1:860 BLUE GENTIAN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1567
Mailing Address - Country:US
Mailing Address - Phone:612-458-8723
Mailing Address - Fax:612-455-2185
Practice Address - Street 1:860 BLUE GENTIAN RD STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1567
Practice Address - Country:US
Practice Address - Phone:612-458-8723
Practice Address - Fax:612-455-2185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-19
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency