Provider Demographics
NPI:1649281676
Name:PATHWAYS PSYCHOLOGY ON GRAND, PLLC
Entity type:Organization
Organization Name:PATHWAYS PSYCHOLOGY ON GRAND, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HIPAA OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEBLOND
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:651-287-0931
Mailing Address - Street 1:1053 GRAND AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3022
Mailing Address - Country:US
Mailing Address - Phone:651-287-0931
Mailing Address - Fax:651-287-0967
Practice Address - Street 1:1053 GRAND AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3022
Practice Address - Country:US
Practice Address - Phone:651-287-0931
Practice Address - Fax:651-287-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN626K2PAOtherBLUE CROSS BLUE SHIELD ID
MN9374051000Medicaid