Provider Demographics
NPI:1831250174
Name:LAURA JEANNE NIEWALD
Entity type:Organization
Organization Name:LAURA JEANNE NIEWALD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:NIEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:612-929-1500
Mailing Address - Street 1:4317 UPTON AVE S
Mailing Address - Street 2:SUITE C
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1539
Mailing Address - Country:US
Mailing Address - Phone:612-929-1500
Mailing Address - Fax:612-929-1500
Practice Address - Street 1:4317 UPTON AVE S
Practice Address - Street 2:SUITE C
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-1539
Practice Address - Country:US
Practice Address - Phone:612-929-1500
Practice Address - Fax:612-929-1500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1216106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN80G34NIOtherBCBS OF MN INDIVID. #
MN478932600OtherMN HEALTH CARE PROGRAMS
MN80G24CLOtherBCBS OF MN CLINIC #