Provider Demographics
NPI:1669071528
Name:LINEAGE COUNSELING
Entity type:Organization
Organization Name:LINEAGE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-716-6795
Mailing Address - Street 1:2000 SHENANDOAH CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-6420
Mailing Address - Country:US
Mailing Address - Phone:612-716-6795
Mailing Address - Fax:
Practice Address - Street 1:4900 HIGHWAY 169 N STE 115
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4058
Practice Address - Country:US
Practice Address - Phone:612-427-8197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty