NPIMap

Organization Active NPI

Center for Self-Growth & Renewal, PC

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Grand Forks, ND
National Provider Identifier
1265658967
Registry record updated Oct 26, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
Legal business name
CENTER FOR SELF-GROWTH & RENEWAL, PC
Practice address
1551 28TH Ave S
Suite C
Grand Forks, ND 58201-6782
Phone
(701) 746-4400
Fax
(701) 746-6034
NPI assigned
Apr 18, 2007
Last updated
Oct 26, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 26, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Laurie Ann Brustad, PHD
Title
Owner
Phone
(701) 746-4400

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X NU Primary

Addresses

Primary practice location

1551 28TH Ave S
Suite C
Grand Forks, ND 58201-6782

Mailing address

1551 28TH Ave S
Suite C
Grand Forks, ND 58201-6782
Phone (701) 746-4400

Other identifiers 1

IdentifierTypeStateIssuer
11912MedicaidND

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041007000473 ND Part B Supplier - Clinic/Group Practice 0042279788 Receives reassigned benefits from 6 practitioners
Practice locations: Grand Forks, ND

National Provider Directory

National Provider Directory

Locations

1551 28th Ave S
Ste C
Grand Forks, ND 58201
Phone (701) 746-4400

600 Demers Ave
#104
Grand Forks, ND 58201
Phone (701) 746-4400

600 Demers Ave
Ste 404
Grand Forks, ND 58201
Phone (701) 746-4400

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176854400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1319587200000",
    "number": "1265658967",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1551 28TH AVE S",
            "address_2": "SUITE C",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582016782",
            "telephone_number": "701-746-4400",
            "fax_number": "701-746-6034"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1551 28TH AVE S",
            "address_2": "SUITE C",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582016782",
            "telephone_number": "701-746-4400",
            "fax_number": "701-746-6034"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTER FOR SELF-GROWTH & RENEWAL, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-18",
        "last_updated": "2011-10-26",
        "status": "A",
        "authorized_official_last_name": "BRUSTAD",
        "authorized_official_first_name": "LAURIE",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "701-746-4400",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11912",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Forks, ND

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.