Provider Demographics
NPI:1508174681
Name:PROFESSIONAL COUNSELING & GRIEF SERVICES INC
Entity Type:Organization
Organization Name:PROFESSIONAL COUNSELING & GRIEF SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEMOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:952-891-2525
Mailing Address - Street 1:14985 GLAZIER AVE
Mailing Address - Street 2:SUITE 555
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7484
Mailing Address - Country:US
Mailing Address - Phone:952-891-2525
Mailing Address - Fax:952-891-1800
Practice Address - Street 1:14985 GLAZIER AVE
Practice Address - Street 2:SUITE 555
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7484
Practice Address - Country:US
Practice Address - Phone:952-891-2525
Practice Address - Fax:952-891-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN055591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800001280Medicare PIN