| Center For Self-growth & Renewal, Pc | |
|
1551 28th Ave S Suite C Grand Forks ND 58201-6782 | |
| (701) 746-4400 | |
| (701) 746-6034 |
| Full Name | Center For Self-growth & Renewal, Pc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1551 28th Ave S, Grand Forks, North Dakota |
| Authorized Official Name and Position | Laurie Ann Brustad (OWNER) |
| Authorized Official Contact | 7017464400 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Center For Self-growth & Renewal, Pc 1551 28th Ave S Suite C Grand Forks ND 58201-6782 Ph: (701) 746-4400 | Center For Self-growth & Renewal, Pc 1551 28th Ave S Suite C Grand Forks ND 58201-6782 Ph: (701) 746-4400 |
| NPI Number | 1265658967 |
|---|---|
| Provider Enumeration Date | 04/18/2007 |
| Last Update Date | 10/26/2011 |
| Medicare PECOS PAC ID | 0042279788 |
|---|---|
| Medicare Enrollment ID | O20041007000473 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1265658967 | NPI | - | NPPES |
| 11912 | Medicaid | ND |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Laurie A Brustad Kennedy |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1326169921 PECOS PAC ID: 2264495886 Enrollment ID: I20041104001122 |
| Provider Name | Winonah Monette |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1477931806 PECOS PAC ID: 3779844469 Enrollment ID: I20180220001861 |
| Provider Name | Avery R Luft |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1053823294 PECOS PAC ID: 8921356866 Enrollment ID: I20180808003199 |
| Provider Name | Matthew R Keller |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1336664614 PECOS PAC ID: 5799048500 Enrollment ID: I20200504002323 |
| Provider Name | Brennan D Atherton |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1215319330 PECOS PAC ID: 4981027190 Enrollment ID: I20200707001484 |
| Provider Name | Kayla J Norton |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1013486166 PECOS PAC ID: 0840603205 Enrollment ID: I20210105000612 |
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