Basic Information
Provider Information | |||||||||
NPI: | 1972006336 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOE | ||||||||
FirstName: | LINDSEY | ||||||||
MiddleName: | RAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEVERTSON | ||||||||
OtherFirstName: | LINDSEY | ||||||||
OtherMiddleName: | RAE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2925 CHICAGO AVE | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122621166 | ||||||||
FaxNumber: | 6122629035 | ||||||||
Practice Location | |||||||||
Address1: | 480 OSBORNE RD NE STE 260 | ||||||||
Address2: |   | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554322866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7632363800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2018 | ||||||||
LastUpdateDate: | 08/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC1700 | MN | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.