Healthcare Provider Details

I. General information

NPI: 1285905885
Provider Name (Legal Business Name): SECURE BASE COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 PROFESSIONAL DR
NORTHFIELD MN
55057-2756
US

IV. Provider business mailing address

570 PROFESSIONAL DR
NORTHFIELD MN
55057-2756
US

V. Phone/Fax

Practice location:
  • Phone: 507-301-3412
  • Fax:
Mailing address:
  • Phone: 507-301-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4079
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 15
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER LYNN SIMPSON-DAHL
Title or Position: CEO/OWNER
Credential: MA, LMFT
Phone: 507-301-3412