Provider Demographics
NPI:1194762005
Name:FAMILY BASED THERAPY ASSOCIATES
Entity type:Organization
Organization Name:FAMILY BASED THERAPY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:763-780-1520
Mailing Address - Street 1:199 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 306
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5831
Mailing Address - Country:US
Mailing Address - Phone:763-780-1520
Mailing Address - Fax:763-780-2114
Practice Address - Street 1:199 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 306
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5831
Practice Address - Country:US
Practice Address - Phone:763-780-1520
Practice Address - Fax:763-780-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty