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General NPI Number Information
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NPI Number | 1639715402
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL RECOVERY ORGANIZATION LLC
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Dates
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Enumeration Date | 11/26/2019
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Last Update Date | 03/19/2024
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Provider Practice Location Address
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Address Line | 700 COMMERCE DR STE 245
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City | WOODBURY
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State | MN
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Zip | 55125-2552
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Country | US
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Telephone | 651-204-9144
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Fax | 651-364-7445
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Provider Business Mailing Address
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Address Line | 700 COMMERCE DR STE 245
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City | WOODBURY
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State | MN
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Zip | 55125-2552
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Country | US
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Telephone | 651-204-9144
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Fax | 651-364-7445
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Authorized Official
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Title or Position | OWNER
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Name | LAUREN FORTMAN
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Credential | MA LPCC LADC
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Telephone | 651-204-9144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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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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