Provider Demographics
NPI:1033545439
Name:BEHAVIORAL WELLNESS COUNSELING CLINIC, LLC
Entity Type:Organization
Organization Name:BEHAVIORAL WELLNESS COUNSELING CLINIC, LLC
Other - Org Name:BEHAVIORAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LEE KLING
Authorized Official - Last Name:KOTVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPCC
Authorized Official - Phone:952-440-3100
Mailing Address - Street 1:14093 COMMERCE AVE NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1495
Mailing Address - Country:US
Mailing Address - Phone:952-440-3100
Mailing Address - Fax:952-440-3100
Practice Address - Street 1:14093 COMMERCE AVE NE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1495
Practice Address - Country:US
Practice Address - Phone:952-440-3100
Practice Address - Fax:952-440-3100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPCC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty