Healthcare Provider Details

I. General information

NPI: 1477821791
Provider Name (Legal Business Name): PROFESSIONAL COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12450 WAYZATA BLVD STE 202
MINNETONKA MN
55305-1927
US

IV. Provider business mailing address

12450 WAYZATA BLVD STE 202
MINNETONKA MN
55305-1927
US

V. Phone/Fax

Practice location:
  • Phone: 952-548-9340
  • Fax: 952-548-9350
Mailing address:
  • Phone: 952-548-9340
  • Fax: 952-548-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARAH GRILL
Title or Position: OFFICE MANAGER
Credential:
Phone: 952-548-9340