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General NPI Number Information
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NPI Number | 1740576354
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Entity Type | Organization
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Legal Business Name | ARK COUNSELING
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Dates
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Enumeration Date | 06/22/2011
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Last Update Date | 07/19/2012
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Provider Practice Location Address
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Address Line | 13895 INDUSTRIAL PARK BLVD
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City | PLYMOUTH
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State | MN
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Zip | 55441-3723
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Country | US
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Telephone | 763-559-5677
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Fax |
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Provider Business Mailing Address
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Address Line | 13895 INDUSTRIAL PARK BLVD
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City | PLYMOUTH
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State | MN
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Zip | 55441-3700
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Country | US
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Telephone | 763-559-5677
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MR. JERRY LEE HOLT
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Credential | MA MPH LPCC LADC
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Telephone | 763-559-5677
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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 | 302560
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 00416
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License Number State | MN
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