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General NPI Number Information
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NPI Number | 1285074039
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Entity Type | Organization
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Legal Business Name | BETHANY CHRISTIAN SERVICES OF MINNESOTA
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Dates
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Enumeration Date | 06/26/2013
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Last Update Date | 03/31/2020
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Provider Practice Location Address
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Address Line | 3131 FERNBROOK LN N STE 204
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City | PLYMOUTH
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State | MN
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Zip | 55447-5337
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Country | US
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Telephone | 763-553-0344
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Fax | 763-553-0117
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Provider Business Mailing Address
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Address Line | 3131 FERNBROOK LN N STE 204
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City | PLYMOUTH
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State | MN
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Zip | 55447-5337
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Country | US
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Telephone | 763-553-0344
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Fax | 763-553-0117
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Authorized Official
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Title or Position | CLINICIAN
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Name | GLORIA PETERSON
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Credential | LICSW
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Telephone | 763-553-0344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 00747
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License Number State | MN
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