Basic Information
| Provider Information | |||||||||
| NPI: | 1023150067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOVAK | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8669 EAGLE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELMO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550428628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513790444 | ||||||||
| FaxNumber: | 6513790448 | ||||||||
| Practice Location | |||||||||
| Address1: | 8669 EAGLE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELMO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550428628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513790444 | ||||||||
| FaxNumber: | 6513790448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 12/30/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 445 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 416K6NO | 01 | MN | BCBS OF MN ID | OTHER |