Healthcare Provider Details

I. General information

NPI: 1124702634
Provider Name (Legal Business Name): PURE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 WILLOW ST STE 201
MINNEAPOLIS MN
55403-3254
US

IV. Provider business mailing address

1409 WILLOW ST STE 201
MINNEAPOLIS MN
55403-3254
US

V. Phone/Fax

Practice location:
  • Phone: 612-562-9021
  • Fax: 866-535-8560
Mailing address:
  • Phone: 612-562-9021
  • Fax: 866-535-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN NOEL PARADISE
Title or Position: PSYCHOTHERAPIST
Credential: LPCC
Phone: 612-227-4597