Healthcare Provider Details

I. General information

NPI: 1124597133
Provider Name (Legal Business Name): TAKE FLIGHT COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 UNIVERSITY AVE W STE S303
SAINT PAUL MN
55104-2813
US

IV. Provider business mailing address

4318 34TH AVE S
MINNEAPOLIS MN
55406-3831
US

V. Phone/Fax

Practice location:
  • Phone: 612-554-9661
  • Fax: 651-645-5970
Mailing address:
  • Phone: 612-554-9661
  • Fax: 651-645-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CONSTANCE LORAINE BENNETT
Title or Position: OWNER
Credential: LPCC
Phone: 612-554-9661