Basic Information
| Provider Information | |||||||||
| NPI: | 1891100293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY BASED THERAPY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554335831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637801520 | ||||||||
| FaxNumber: | 7637802114 | ||||||||
| Practice Location | |||||||||
| Address1: | 11549 LAKE LN | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CHISAGO CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550139830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512572733 | ||||||||
| FaxNumber: | 6512572783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 06/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7637801520 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 00789 | MN | Y | Agencies | Community/Behavioral Health |
No ID Information.