Provider Demographics
NPI:1275037277
Name:EDEN THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:EDEN THERAPY CENTER, LLC
Other - Org Name:EDEN THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-807-6516
Mailing Address - Street 1:800 PRAIRIE CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7328
Mailing Address - Country:US
Mailing Address - Phone:952-234-9210
Mailing Address - Fax:952-204-3933
Practice Address - Street 1:800 PRAIRIE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7328
Practice Address - Country:US
Practice Address - Phone:952-234-9210
Practice Address - Fax:952-204-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01257101YM0800X
171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1811349764OtherNPI
MN1861944761OtherNPI