Provider Demographics
NPI:1275350993
Name:TULLY, ALEXANDRIA (LMFT)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1957 168TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5417
Mailing Address - Country:US
Mailing Address - Phone:763-360-0554
Mailing Address - Fax:763-360-0554
Practice Address - Street 1:760 STILLWATER RD UNIT 101
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-2060
Practice Address - Country:US
Practice Address - Phone:763-360-0554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4685106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist