Healthcare Provider Details

I. General information

NPI: 1720347875
Provider Name (Legal Business Name): A CHANCE TO GROW, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 2ND ST NE
MINNEAPOLIS MN
55418-4306
US

IV. Provider business mailing address

1800 2ND ST NE
MINNEAPOLIS MN
55418-4306
US

V. Phone/Fax

Practice location:
  • Phone: 612-789-1236
  • Fax: 612-706-5555
Mailing address:
  • Phone: 612-789-1236
  • Fax: 612-706-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2605
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2605
License Number StateMN

VIII. Authorized Official

Name: MRS. ERICA DICKERSON
Title or Position: CLINICAL DIRECTOR
Credential: M.A. CCC/SLP
Phone: 612-706-5538