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General NPI Number Information
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NPI Number | 1992456073
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Entity Type | Organization
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Legal Business Name | IMAGINE NATION LLC
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Dates
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Enumeration Date | 01/11/2022
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Last Update Date | 01/11/2022
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Provider Practice Location Address
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Address Line | 3333 W DIVISION ST STE 100
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City | SAINT CLOUD
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State | MN
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Zip | 56301-4555
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Country | US
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Telephone | 320-266-8082
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Fax |
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Provider Business Mailing Address
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Address Line | 417 5TH AVE N
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City | SARTELL
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State | MN
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Zip | 56377-1653
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Country | US
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Telephone | 320-266-8082
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARC VAN HERR
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Credential |
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Telephone | 320-266-8082
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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 |
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License Number State |
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