Provider Demographics
NPI:1457628877
Name:LUMEN PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:LUMEN PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER / PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRITT
Authorized Official - Middle Name:NICOLE SHACKELFORD
Authorized Official - Last Name:WESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:612-787-7050
Mailing Address - Street 1:3503 HIGHPOINT DR N STE 230
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-7577
Mailing Address - Country:US
Mailing Address - Phone:612-787-7050
Mailing Address - Fax:
Practice Address - Street 1:3503 HIGHPOINT DR N STE 230
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-7577
Practice Address - Country:US
Practice Address - Phone:612-787-7050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 5297251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health