Healthcare Provider Details

I. General information

NPI: 1548970825
Provider Name (Legal Business Name): INTEGRATIVE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4524 46TH AVE S
MINNEAPOLIS MN
55406-3620
US

IV. Provider business mailing address

4524 46TH AVE S
MINNEAPOLIS MN
55406-3620
US

V. Phone/Fax

Practice location:
  • Phone: 612-245-5229
  • Fax:
Mailing address:
  • Phone: 612-245-5229
  • 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 Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL LEE NELSON
Title or Position: LICENSED MARRIAGE & FAMILY THERAPIS
Credential: MA, LMFT
Phone: 612-245-5229