Provider Demographics
NPI:1376384370
Name:MIDWEST MINDS ASSESSMENT AND THERAPY, PLLC
Entity type:Organization
Organization Name:MIDWEST MINDS ASSESSMENT AND THERAPY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIPPOOLDT-BACA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP, ABPP
Authorized Official - Phone:651-283-0639
Mailing Address - Street 1:1937 WOODLANE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4043
Mailing Address - Country:US
Mailing Address - Phone:651-764-8480
Mailing Address - Fax:
Practice Address - Street 1:1937 WOODLANE DR STE 101
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4043
Practice Address - Country:US
Practice Address - Phone:651-764-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-04
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1356698294Medicaid
MN1467712182Medicaid
MN1568606077Medicaid