Healthcare Provider Details

I. General information

NPI: 1417116344
Provider Name (Legal Business Name): OVERSON FAMILY BASED COUNSELING SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47205 336TH ST
GAYLORD MN
55334-2241
US

IV. Provider business mailing address

47205 336TH ST
GAYLORD MN
55334-2241
US

V. Phone/Fax

Practice location:
  • Phone: 507-327-4064
  • Fax: 507-237-2647
Mailing address:
  • Phone: 507-327-4064
  • Fax: 507-237-2647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number17672
License Number StateMN

VIII. Authorized Official

Name: COLLEEN OVERSON
Title or Position: FAMILY BASED THERAPIST
Credential: LICSW
Phone: 507-327-4064