Healthcare Provider Details

I. General information

NPI: 1063264612
Provider Name (Legal Business Name): RESILIENT FUSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3662 POINTE PASS NW
PRIOR LAKE MN
55372-4555
US

IV. Provider business mailing address

3662 POINTE PASS NW
PRIOR LAKE MN
55372-4555
US

V. Phone/Fax

Practice location:
  • Phone: 952-210-2724
  • Fax:
Mailing address:
  • Phone: 952-210-2724
  • Fax:

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: LATASHA PETERSON
Title or Position: OWNER
Credential: LPCC
Phone: 952-210-2724