Provider Demographics
NPI:1528103595
Name:NISJA, GENE M (LMFT)
Entity type:Individual
Prefix:
First Name:GENE
Middle Name:M
Last Name:NISJA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7982 HALIFAX AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2644
Mailing Address - Country:US
Mailing Address - Phone:612-325-7382
Mailing Address - Fax:
Practice Address - Street 1:7362 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 209
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3142
Practice Address - Country:US
Practice Address - Phone:612-825-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLMFT 1632106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist