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General NPI Number Information
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NPI Number | 1699102434
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Entity Type | Organization
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Legal Business Name | COLLABORATIVE RESTORATION COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 10/10/2013
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Last Update Date | 10/10/2013
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Provider Practice Location Address
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Address Line | 15252 W FREEWAY DR NE SUITE 1
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City | FOREST LAKE
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State | MN
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Zip | 55025-8120
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Country | US
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Telephone | 612-275-3517
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Fax |
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Provider Business Mailing Address
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Address Line | 7500 CAHILL RD 216C
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City | EDINA
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State | MN
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Zip | 55439-2734
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Country | US
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Telephone | 612-275-3517
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Fax |
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Authorized Official
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Title or Position | FOUNDER/OWNDER
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Name | MRS. LAURA JANELLE MCDERMOTT
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Credential | LMFT
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Telephone | 612-275-3517
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 2619
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License Number State | MN
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