| Organization Name: | BEHAVIORAL WELLNESS COUNSELING CLINIC, LLC |
| NPI Number: | 1033545439 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TRACY LEE KLING KOTVAL (DIRECTOR) |
| Mailing Address: | 14093 Commerce Ave Ne Prior Lake |
| State: | MN US |
| Postal Code: | 553721495 |
| Phone Number: | 9524403100 |
| Fax Number: | 9524403100 |
| NPI Enumeration Date: | 09/18/2013 |
| NPI Last Update Date: | 09/18/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | LPCC |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |