NPIMap

Organization Active NPI

Family Based Therapy Associates

  • Mental Health Counselor
  • Coon Rapids, MN
National Provider Identifier
1194762005
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health CounselorTaxonomy code 101YM0800X
Legal business name
FAMILY BASED THERAPY ASSOCIATES
Practice address
199 Coon Rapids Blvd NW
Suite 306
Coon Rapids, MN 55433-5831
Phone
(763) 780-1520
Fax
(763) 780-2114
NPI assigned
May 31, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Randall D Wallace, LPNPI 1689768707
Title
Director
Phone
(763) 780-1520

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193400000X SINGLE SPECIALTY GROUP 101YM0800X Primary

Addresses

Primary practice location

199 Coon Rapids Blvd NW
Suite 306
Coon Rapids, MN 55433-5831

Mailing address

199 Coon Rapids Blvd NW
Suite 306
Coon Rapids, MN 55433-5831
Phone (763) 780-1520

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070110000019 MN Part B Supplier - Clinic/Group Practice 2264432681 Receives reassigned benefits from 21 practitioners
Practice locations: Cambridge, MN; Chisago City, MN; Coon Rapids, MN

National Provider Directory

National Provider Directory
Tax ID family
Family Based Therapy Associates2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

133 2nd Ave SW
Cambridge, MN 55008
Phone (763) 689-9407

237 2nd Ave SW
Ste 117
Cambridge, MN 55008
Phone (763) 200-3411

199 Coon Rapids Blvd NW
Ste 306
Minneapolis, MN 55433
Phone (763) 780-1520

Practitioners & affiliated clinicians

Practitioners 54

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 54

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149033600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1194762005",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "199 COON RAPIDS BLVD NW",
            "address_2": "SUITE 306",
            "city": "COON RAPIDS",
            "state": "MN",
            "postal_code": "554335831",
            "telephone_number": "763-780-1520",
            "fax_number": "763-780-2114"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "199 COON RAPIDS BLVD NW",
            "address_2": "SUITE 306",
            "city": "COON RAPIDS",
            "state": "MN",
            "postal_code": "554335831",
            "telephone_number": "763-780-1520",
            "fax_number": "763-780-2114"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY BASED THERAPY ASSOCIATES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-31",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "RANDALL",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "763-780-1520",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "LP"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Coon Rapids, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.