1366766206 NPI number — SERENITY CIRCLE COUNSELING, LLC

Table of content: (NPI 1366766206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366766206 NPI number — SERENITY CIRCLE COUNSELING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY CIRCLE COUNSELING, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SERENITY CIRCLE COUNSELING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366766206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISANTI
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55040-0023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-600-2911
Provider Business Mailing Address Fax Number:
763-244-1243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 MAIN STREET W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISANTI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55040-5504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-600-2911
Provider Business Practice Location Address Fax Number:
763-244-1243
Provider Enumeration Date:
03/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BUNES
Authorized Official First Name:
DEANNA
Authorized Official Middle Name:
LEA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-600-2911

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 682645300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 444428200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com