Healthcare Provider Details

I. General information

NPI: 1386909281
Provider Name (Legal Business Name): PROFOUND THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2012
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 8TH AVE N
SAINT CLOUD MN
56303-3420
US

IV. Provider business mailing address

720 8TH AVE N
SAINT CLOUD MN
56303-3420
US

V. Phone/Fax

Practice location:
  • Phone: 320-266-1693
  • Fax: 320-251-0217
Mailing address:
  • Phone: 320-266-1693
  • Fax: 320-251-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: NICOLE J OTIS
Title or Position: OWNER - MARRIAGE & FAMILY THERAPIST
Credential: LMFT
Phone: 320-266-1693