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General NPI Number Information
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NPI Number | 1427432087
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Entity Type | Organization
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Legal Business Name | MAPLE GROVE THERAPY AND WELLNESS
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Dates
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Enumeration Date | 07/14/2015
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Last Update Date | 07/14/2015
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Provider Practice Location Address
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Address Line | 7200 FORESTVIEW LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55369-5571
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Country | US
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Telephone | 763-200-1466
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Fax |
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Provider Business Mailing Address
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Address Line | 7200 FORESTVIEW LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55369-5571
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Country | US
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Telephone | 763-200-1466
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Fax |
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Authorized Official
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Title or Position | OWNER, PSYCHOTHERAPIST
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Name | KELLY JO WESNER
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Credential | MSW, LICSW
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Telephone | 763-200-1466
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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 | 17743
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License Number State | MN
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