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General NPI Number Information
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NPI Number | 1487001400
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Entity Type | Organization
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Legal Business Name | CHANGING STRIDES THERAPY LLC
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Dates
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Enumeration Date | 05/19/2016
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 10010 STRAWBERRY LAKE RD
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City | PEQUOT LAKES
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State | MN
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Zip | 56472-2291
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Country | US
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Telephone | 218-833-7636
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Fax | 218-543-4394
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Provider Business Mailing Address
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Address Line | PO BOX 625
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City | CROSSLAKE
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State | MN
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Zip | 56442-0625
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Country | US
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Telephone | 218-833-7636
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Fax | 218-543-4394
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Authorized Official
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Title or Position | COUNSELOR
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Name | STACY LOUISE GUSTAFSON
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Credential | LPCC
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Telephone | 218-833-7636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | CC01066
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License Number State | MN
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