| The Storefront Group | |
|
6425 Nicollet Ave Richfield MN 55423-1668 | |
| (612) 861-1675 | |
| (612) 861-3446 |
| Full Name | The Storefront Group |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 6425 Nicollet Ave, Richfield, Minnesota |
| Authorized Official Name and Position | Patrick Dale (CEO) |
| Authorized Official Contact | 6128611675 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| The Storefront Group 6425 Nicollet Ave Richfield MN 55423-1668 Ph: (612) 861-1675 | The Storefront Group 6425 Nicollet Ave Richfield MN 55423-1668 Ph: (612) 861-1675 |
| NPI Number | 1386728228 |
|---|---|
| Provider Enumeration Date | 10/25/2006 |
| Last Update Date | 05/17/2023 |
| Certification Date | 05/17/2023 |
| Medicare PECOS PAC ID | 0840197828 |
|---|---|
| Medicare Enrollment ID | O20031217000719 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1386728228 | NPI | - | NPPES |
| 875055600 | Medicaid | MN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (Minnesota) | Primary |
| Provider Name | Joan Marie Gibson |
|---|---|
| Provider Type | Practitioner - Certified Clinical Nurse Specialist (cns) |
| Provider Identifiers | NPI Number: 1518916071 PECOS PAC ID: 7719959790 Enrollment ID: I20040810000979 |
| Provider Name | Richard A Blackburn |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1134293400 PECOS PAC ID: 0345242657 Enrollment ID: I20070215000025 |
| Provider Name | Sandra R Lindell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1285871277 PECOS PAC ID: 5294892253 Enrollment ID: I20090319000320 |
| Provider Name | Julie A Heckathorne |
|---|---|
| Provider Type | Practitioner - Certified Clinical Nurse Specialist (cns) |
| Provider Identifiers | NPI Number: 1285830182 PECOS PAC ID: 9537211925 Enrollment ID: I20090715000750 |
| Provider Name | Macarena M Corral |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1538443452 PECOS PAC ID: 8022276476 Enrollment ID: I20120215000187 |
| Provider Name | Nicole J Slavik |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1609210251 PECOS PAC ID: 8426291410 Enrollment ID: I20130823000048 |
| Provider Name | Noureen M Wallani |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1780019935 PECOS PAC ID: 6800020280 Enrollment ID: I20131018001022 |
| Provider Name | Jeffrey L Mills |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1609247048 PECOS PAC ID: 9032429188 Enrollment ID: I20151102002689 |
| Provider Name | Kathryn L Isham |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1023551702 PECOS PAC ID: 5890076541 Enrollment ID: I20170111002726 |
| Provider Name | Vanessa Boerhave |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1639680473 PECOS PAC ID: 7618234675 Enrollment ID: I20171129000711 |
| Provider Name | Randall L Morris Ostrom |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1174891618 PECOS PAC ID: 4385901347 Enrollment ID: I20171129001015 |
| Provider Name | Karin L Muldowney |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1346752359 PECOS PAC ID: 8527325059 Enrollment ID: I20171207002953 |
| Provider Name | Katelyn E Nichols |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1801389911 PECOS PAC ID: 2769732494 Enrollment ID: I20180830000722 |
| Provider Name | Teri L Clayton |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1598921140 PECOS PAC ID: 3072866680 Enrollment ID: I20181030000175 |
| Provider Name | Ryan D Hovis |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1326397092 PECOS PAC ID: 9638406432 Enrollment ID: I20190815002467 |
| Provider Name | Claire Kd Welsch |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1629613351 PECOS PAC ID: 9335573690 Enrollment ID: I20191220000022 |
| Provider Name | Amanda E Berg |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1841899366 PECOS PAC ID: 9335556158 Enrollment ID: I20210323002185 |
| Provider Name | Alexandra Bonyata |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1770296634 PECOS PAC ID: 8527430719 Enrollment ID: I20230216002381 |
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