Provider Demographics
NPI:1053948315
Name:61 EXPERIENCE
Entity type:Organization
Organization Name:61 EXPERIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-418-9429
Mailing Address - Street 1:3822 REGENT AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2019
Mailing Address - Country:US
Mailing Address - Phone:612-418-9429
Mailing Address - Fax:
Practice Address - Street 1:1 WATER ST W STE 230
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2002
Practice Address - Country:US
Practice Address - Phone:612-418-9429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty