Provider Demographics
NPI:1063744662
Name:AGAPE COUNSELING CENTER LLC
Entity type:Organization
Organization Name:AGAPE COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HECKENLAIBLE-GOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:507-822-3177
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-0293
Mailing Address - Country:US
Mailing Address - Phone:507-832-8033
Mailing Address - Fax:507-832-8298
Practice Address - Street 1:305 9TH ST
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1658
Practice Address - Country:US
Practice Address - Phone:507-832-8033
Practice Address - Fax:507-832-8298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YA0400X
MN4507103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty