Provider Demographics
NPI:1669114195
Name:MEMENGWAA PSYCHOTHERAPY
Entity type:Organization
Organization Name:MEMENGWAA PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:IRRGANG-WADE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC, CTMH
Authorized Official - Phone:218-839-9886
Mailing Address - Street 1:13109 TWILIGHT RD
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7919
Mailing Address - Country:US
Mailing Address - Phone:218-839-9886
Mailing Address - Fax:
Practice Address - Street 1:518 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-4544
Practice Address - Country:US
Practice Address - Phone:218-839-9886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty