=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437741964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENDIPITY COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2021
-----------------------------------------------------
Last Update Date | 02/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7650 CURRELL BLVD STE 305
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-2257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-964-9293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7650 CURRELL BLVD STE 305
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-2257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-964-9293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANGELA RACKSTRAW
-----------------------------------------------------
Credential | MSW, LICSW, PMH-C
-----------------------------------------------------
Telephone | 651-964-9293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------