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General NPI Number Information
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NPI Number | 1386909281
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Entity Type | Organization
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Legal Business Name | PROFOUND THERAPY LLC
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Dates
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Enumeration Date | 07/07/2012
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Last Update Date | 01/13/2014
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Provider Practice Location Address
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Address Line | 720 8TH AVE N
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City | SAINT CLOUD
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State | MN
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Zip | 56303-3420
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Country | US
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Telephone | 320-266-1693
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Fax | 320-251-0217
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Provider Business Mailing Address
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Address Line | 720 8TH AVE N
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City | SAINT CLOUD
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State | MN
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Zip | 56303-3420
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Country | US
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Telephone | 320-266-1693
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Fax | 320-251-0217
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Authorized Official
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Title or Position | OWNER - MARRIAGE & FAMILY THERAPIST
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Name | NICOLE J OTIS
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Credential | LMFT
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Telephone | 320-266-1693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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