Provider Demographics
NPI:1285979047
Name:GILDERSLEEVE COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:GILDERSLEEVE COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:B
Authorized Official - Last Name:GILDERSLEEVE
Authorized Official - Suffix:
Authorized Official - Credentials:MS,LP
Authorized Official - Phone:612-386-3365
Mailing Address - Street 1:801 TWELVE OAKS CENTER DR
Mailing Address - Street 2:803B
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4601
Mailing Address - Country:US
Mailing Address - Phone:952-303-5487
Mailing Address - Fax:
Practice Address - Street 1:801 TWELVE OAKS CENTER DR
Practice Address - Street 2:803B
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4601
Practice Address - Country:US
Practice Address - Phone:952-303-5487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3779251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN934215000Medicaid