{
"Npi": {
"NPI": "1699278283",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "RENEW YOUR MIND - COUNSELING CONSULTING AND SUPERVISION LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "9705N VIOLET LN",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "HAYWARD",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "54843-1179",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "651-380-2235",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "15561 RAILROAD ST STE 203A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HAYWARD",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "54843-5703",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "651-347-1380",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/09/2018",
"LastUpdateDate": "05/16/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BOOZELL",
"AuthorizedOfficialFirstName": "LESLEY",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "CREDENTIAL SPECIALIST",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "218-232-0856",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101YA0400X",
"TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
"LicenseNumber": "302869",
"LicenseNumberStateCode": "MN",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "101YP2500X",
"TaxonomyName": "Professional Counselor",
"LicenseNumber": "CC01151",
"LicenseNumberStateCode": "MN",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}