Basic Information
Provider Information | |||||||||
NPI: | 1720477300 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEEKLEY | ||||||||
FirstName: | NOHEMI | ||||||||
MiddleName: | ENNA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11170 68TH ST NE | ||||||||
Address2: |   | ||||||||
City: | ALBERTVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 553014582 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7637801520 | ||||||||
FaxNumber: | 7637802114 | ||||||||
Practice Location | |||||||||
Address1: | 199 COON RAPIDS BLVD NW STE 306 | ||||||||
Address2: |   | ||||||||
City: | COON RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 554335861 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7637801520 | ||||||||
FaxNumber: | 7637802114 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2015 | ||||||||
LastUpdateDate: | 04/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 2833 | MN | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.