Healthcare Provider Details

I. General information

NPI: 1578331583
Provider Name (Legal Business Name): FLOURISH WELLNESS COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 PORTLAND AVE STE 180
BURNSVILLE MN
55337-6875
US

IV. Provider business mailing address

12400 PORTLAND AVE STE 180
BURNSVILLE MN
55337-6875
US

V. Phone/Fax

Practice location:
  • Phone: 952-405-9601
  • Fax: 952-405-9571
Mailing address:
  • Phone: 952-405-9601
  • Fax: 952-405-9571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MAGGIE WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 952-405-9601