Healthcare Provider Details

I. General information

NPI: 1447713672
Provider Name (Legal Business Name): CULTIVATE COUNSELING AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2019
Last Update Date: 04/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 1ST AVE NE STE 405
MINNEAPOLIS MN
55413-2447
US

IV. Provider business mailing address

1212 MAIN ST NE APT 237
MINNEAPOLIS MN
55413-1398
US

V. Phone/Fax

Practice location:
  • Phone: 612-849-5665
  • Fax:
Mailing address:
  • Phone: 612-849-5665
  • Fax:

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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JANELLE ZIMMERMAN
Title or Position: OWNER/THERAPIST
Credential: LPCC
Phone: 612-849-5665