Organization
FAMILY BASED THERAPY ASSOCIATES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RANDALL D WALLACE LP (DIRECTOR)
(763) 780-1520
Entity
Organization
Contact information
Practice address
199 COON RAPIDS BLVD NW, SUITE 306, COON RAPIDS, MN 55433-5831
(763) 780-1520
(763) 780-2114
Mailing address
199 COON RAPIDS BLVD NW, SUITE 306, COON RAPIDS, MN 55433-5831
(763) 780-1520
(763) 780-2114
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
Other
Enumeration date
05/31/2006
Last updated
08/22/2020
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