Provider Demographics
NPI:1891100293
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:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
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 1:11549 LAKE LN
Practice Address - Street 2:SUITE 2
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9830
Practice Address - Country:US
Practice Address - Phone:651-257-2733
Practice Address - Fax:651-257-2783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00789251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health