Provider Demographics
NPI:1275375297
Name:PRISMATIC PSYCHOTHERAPY, PLLC
Entity type:Organization
Organization Name:PRISMATIC PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:SEVERNS
Authorized Official - Last Name:GUNTZEL
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:612-440-8931
Mailing Address - Street 1:4144 21ST AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3074
Mailing Address - Country:US
Mailing Address - Phone:612-978-3321
Mailing Address - Fax:
Practice Address - Street 1:4801 1/2 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-5510
Practice Address - Country:US
Practice Address - Phone:612-440-8931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health