Provider Demographics
NPI:1770912271
Name:MN COUPLE THERAPY CENTER
Entity type:Organization
Organization Name:MN COUPLE THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WICAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-340-4597
Mailing Address - Street 1:1611 COUNTY ROAD B W
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5021
Mailing Address - Country:US
Mailing Address - Phone:651-340-4597
Mailing Address - Fax:651-340-4597
Practice Address - Street 1:1611 COUNTY ROAD B W
Practice Address - Street 2:SUITE 303
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-5021
Practice Address - Country:US
Practice Address - Phone:651-340-4597
Practice Address - Fax:651-340-4597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1357261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)