Provider Demographics
NPI:1386909281
Name:PROFOUND THERAPY LLC
Entity type:Organization
Organization Name:PROFOUND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - MARRIAGE & FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:OTIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:320-266-1693
Mailing Address - Street 1:720 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-3420
Mailing Address - Country:US
Mailing Address - Phone:320-266-1693
Mailing Address - Fax:320-251-0217
Practice Address - Street 1:720 8TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-3420
Practice Address - Country:US
Practice Address - Phone:320-266-1693
Practice Address - Fax:320-251-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-07
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty