Healthcare Provider Details

I. General information

NPI: 1750225611
Provider Name (Legal Business Name): 10,000 LAKES HEALING & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9820 GARLAND LN N APT B206
MAPLE GROVE MN
55311-4728
US

IV. Provider business mailing address

9820 GARLAND LN N APT B206
MAPLE GROVE MN
55311-4728
US

V. Phone/Fax

Practice location:
  • Phone: 651-900-3889
  • Fax:
Mailing address:
  • Phone: 651-900-3889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHARLES WEILL
Title or Position: MENTAL HEALTH THERAPIST
Credential: LGSW
Phone: 651-900-3889