Healthcare Provider Details

I. General information

NPI: 1154826469
Provider Name (Legal Business Name): NOLAN'S PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 19TH AVE SW
WILLMAR MN
56201-5274
US

IV. Provider business mailing address

515 19TH AVE SW
WILLMAR MN
56201-5274
US

V. Phone/Fax

Practice location:
  • Phone: 320-403-5247
  • Fax: 320-403-5249
Mailing address:
  • Phone: 320-403-5247
  • Fax: 320-403-5249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SALLIE GRAVES
Title or Position: OWNER
Credential:
Phone: 507-401-1467