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General NPI Number Information
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NPI Number | 1023511714
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Entity Type | Organization
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Legal Business Name | GRANDER LIVING LLC
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Dates
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Enumeration Date | 03/09/2018
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Last Update Date | 03/09/2018
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Provider Practice Location Address
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Address Line | 7924 VICTORIA DR STE 201C
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City | VICTORIA
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State | MN
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Zip | 55386-2801
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Country | US
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Telephone | 952-220-9283
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2 7924 VICTORIA DRIVE STE. 201C
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City | VICTORIA
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State | MN
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Zip | 55386
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Country | US
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Telephone | 952-220-9283
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Fax |
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Authorized Official
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Title or Position | OWNER, MENTAL HEALTH COUNSELOR
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Name | RENEE E CARLSON
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Credential | LPCC-S, RPT-S
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Telephone | 952-220-9283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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