MEDICARE: PURE THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1124702634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE THERAPY, LLC

Provider Business Mailing Address
First Line	:	1409 WILLOW ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3254
Country	:	US
Telephone Number	:	612-562-9021
Fax Number	:	866-535-8560

Provider Business Practice Location Address
First Line	:	1409 WILLOW ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3254
Country	:	US
Telephone Number	:	612-562-9021
Fax Number	:	866-535-8560

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	KRISTEN NOEL PARADISE
Credential	:	LPCC
Telephone Number	:	612-227-4597

Provider Enumeration Date	:	06/14/2023
Last Update Date	:	07/15/2024

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Directions to “PURE THERAPY, LLC ” Practice Location

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