Provider Demographics
NPI:1487065660
Name:TWIN CITIES PSYCHOLOGICAL SERVICES, LTD.
Entity type:Organization
Organization Name:TWIN CITIES PSYCHOLOGICAL SERVICES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-345-5194
Mailing Address - Street 1:825 NICOLLET MALL STE 1455
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2703
Mailing Address - Country:US
Mailing Address - Phone:612-345-5194
Mailing Address - Fax:
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 1455
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-345-5194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5726251S00000X
MNLP5724251S00000X
103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1407185564OtherNPI
VA179-0012-318OtherNPI