Healthcare Provider Details

I. General information

NPI: 1386580884
Provider Name (Legal Business Name): THE RENEGADE THERAPIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WASHINGTON ST # 288
NORTHFIELD MN
55057-2027
US

IV. Provider business mailing address

400 WASHINGTON ST # 288
NORTHFIELD MN
55057-2027
US

V. Phone/Fax

Practice location:
  • Phone: 262-587-5750
  • Fax: 262-394-0828
Mailing address:
  • Phone: 262-587-5750
  • Fax: 262-394-0828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: RACHEL MORRISON
Title or Position: OWNER, PSYCHOTHERAPIST
Credential: LICSW
Phone: 262-587-5750