Provider Demographics
NPI:1548488331
Name:INSTITUTE FOR THERAPY & BEHAVIOR CHANGE, LTD.
Entity type:Organization
Organization Name:INSTITUTE FOR THERAPY & BEHAVIOR CHANGE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONLON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:952-922-1977
Mailing Address - Street 1:3919 W 44TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1032
Mailing Address - Country:US
Mailing Address - Phone:952-922-1977
Mailing Address - Fax:952-922-1980
Practice Address - Street 1:3919 W 44TH ST STE 200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1032
Practice Address - Country:US
Practice Address - Phone:952-922-1977
Practice Address - Fax:952-922-1980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN07678INOtherBLUE SHIELD GROUP NUMBER