Organization
FAMILY BASED THERAPY ASSOCIATES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RANDALL WALLACE LP (DIRECTOR)
(763) 780-1520
Entity
Organization
Contact information
Practice address
11549 LAKE LN, SUITE 2, CHISAGO CITY, MN 55013-9830
(651) 257-2733
(651) 257-2783
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
251S00000X
Community/Behavioral Health Agency
Primary
00789
MN
Other
Enumeration date
06/24/2014
Last updated
06/24/2014
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