Provider Demographics
NPI:1265658967
Name:CENTER FOR SELF-GROWTH & RENEWAL, PC
Entity Type:Organization
Organization Name:CENTER FOR SELF-GROWTH & RENEWAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-746-4400
Mailing Address - Street 1:1551 28TH AVE S
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6782
Mailing Address - Country:US
Mailing Address - Phone:701-746-4400
Mailing Address - Fax:701-746-6034
Practice Address - Street 1:1551 28TH AVE S
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6782
Practice Address - Country:US
Practice Address - Phone:701-746-4400
Practice Address - Fax:701-746-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11912Medicaid
NDN71158Medicare PIN