Healthcare Provider Details

I. General information

NPI: 1952712572
Provider Name (Legal Business Name): CAMBRIDGE COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 ADAMS ST S
CAMBRIDGE MN
55008-1620
US

IV. Provider business mailing address

21221 FOXTAIL LN
ROGERS MN
55374-6512
US

V. Phone/Fax

Practice location:
  • Phone: 763-442-4111
  • Fax:
Mailing address:
  • Phone: 763-443-2096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4821
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL KELLER
Title or Position: OWNER
Credential: LP
Phone: 763-442-4111