MEDICARE: THRIVE THERAPEUTIC SERVICES, 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	1041C0700X	Clinical Social Worker
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1811699176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THRIVE THERAPEUTIC SERVICES, LLC

Provider Business Mailing Address
First Line	:	620 CIVIC HEIGHTS DR
Second Line	:
City	:	CIRCLE PINES
State	:	MN
Zip	:	55014-4711
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 CIVIC HEIGHTS DR
Second Line	:
City	:	CIRCLE PINES
State	:	MN
Zip	:	55014-4711
Country	:	US
Telephone Number	:	763-248-0352
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KELLY LEMM
Credential	:
Telephone Number	:	612-501-5242

Provider Enumeration Date	:	03/20/2023
Last Update Date	:	03/20/2023

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