Healthcare Provider Details

I. General information

NPI: 1578007969
Provider Name (Legal Business Name): CULTIVATING FAMILY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 COUNTY ROAD 10 SUITE 304I
BROOKLYN CENTER MN
55429-3072
US

IV. Provider business mailing address

3300 COUNTY ROAD 10 STE 304I
BROOKLYN CENTER MN
55429-3066
US

V. Phone/Fax

Practice location:
  • Phone: 763-355-5461
  • Fax: 763-355-5692
Mailing address:
  • Phone: 763-355-5461
  • Fax: 763-355-5692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25186
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3003
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3003, 25186
License Number StateMN

VIII. Authorized Official

Name: KESHA GREEN
Title or Position: DIRECTOR
Credential: LMFT, LICSW
Phone: 763-355-5461