Provider Demographics
NPI:1063519262
Name:CENTER FOR PERSONAL & PROFESSIONAL GROWTH, LLC
Entity type:Organization
Organization Name:CENTER FOR PERSONAL & PROFESSIONAL GROWTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MS LP
Authorized Official - Phone:507-252-5700
Mailing Address - Street 1:400 S BROADWAY
Mailing Address - Street 2:STE 16
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904
Mailing Address - Country:US
Mailing Address - Phone:507-252-5700
Mailing Address - Fax:507-252-8115
Practice Address - Street 1:400 S BROADWAY
Practice Address - Street 2:STE 16
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904
Practice Address - Country:US
Practice Address - Phone:507-252-5700
Practice Address - Fax:507-252-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3327103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN806023100Medicaid