Healthcare Provider Details

I. General information

NPI: 1548086689
Provider Name (Legal Business Name): THE GROWTH GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13784 83RD WAY N STE 200
MAPLE GROVE MN
55369-7207
US

IV. Provider business mailing address

12425 WATERSIDE CT
ROGERS MN
55374-3300
US

V. Phone/Fax

Practice location:
  • Phone: 724-261-7703
  • Fax:
Mailing address:
  • Phone: 724-261-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: REBECCA BAKKER
Title or Position: OWNER
Credential: LPCC
Phone: 724-261-7703