Provider Demographics
NPI:1023511714
Name:GRANDER LIVING LLC
Entity type:Organization
Organization Name:GRANDER LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S, RPT-S
Authorized Official - Phone:952-220-9283
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:7924 VICTORIA DRIVE STE. 201C
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386
Mailing Address - Country:US
Mailing Address - Phone:952-220-9283
Mailing Address - Fax:
Practice Address - Street 1:7924 VICTORIA DR STE 201C
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:MN
Practice Address - Zip Code:55386-2801
Practice Address - Country:US
Practice Address - Phone:952-220-9283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)