Provider Demographics
| NPI: | 1639715402 |
|---|---|
| Name: | PROFESSIONAL RECOVERY ORGANIZATION LLC |
| Entity Type: | Organization |
| Organization Name: | PROFESSIONAL RECOVERY ORGANIZATION LLC |
| Other - Org Name: | PRO RECOVERY AND THERAPY |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | OWNER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | LAUREN |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | FORTMAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MA LPCC LADC |
| Authorized Official - Phone: | 651-204-9144 |
| Mailing Address - Street 1: | 700 COMMERCE DR STE 245 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | WOODBURY |
| Mailing Address - State: | MN |
| Mailing Address - Zip Code: | 55125-2552 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 651-204-9144 |
| Mailing Address - Fax: | 651-364-7445 |
| Practice Address - Street 1: | 700 COMMERCE DR STE 245 |
| Practice Address - Street 2: | |
| Practice Address - City: | WOODBURY |
| Practice Address - State: | MN |
| Practice Address - Zip Code: | 55125-2552 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 651-204-9144 |
| Practice Address - Fax: | 651-364-7445 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2019-11-26 |
| Last Update Date: | 2024-03-19 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | Group - Multi-Specialty |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family | Group - Multi-Specialty |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
