Provider Demographics
NPI:1336404821
Name:TLC
Entity Type:Organization
Organization Name:TLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTENS ENDRIZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-554-5005
Mailing Address - Street 1:6311 WAYZATA BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1209
Mailing Address - Country:US
Mailing Address - Phone:952-545-0200
Mailing Address - Fax:
Practice Address - Street 1:5641 AUDREY AVE
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55077-1812
Practice Address - Country:US
Practice Address - Phone:612-554-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LYMPHEDEMA CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101152225X00000X
MN5742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty