Provider Demographics
NPI:1134665748
Name:BRISTLECONE TO GO, INC.
Entity type:Organization
Organization Name:BRISTLECONE TO GO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, COO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:763-913-4600
Mailing Address - Street 1:13700 REIMER DR N
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4580
Mailing Address - Country:US
Mailing Address - Phone:763-424-2474
Mailing Address - Fax:763-424-2711
Practice Address - Street 1:13700 REIMER DR N
Practice Address - Street 2:SUITE 220
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4580
Practice Address - Country:US
Practice Address - Phone:763-424-2474
Practice Address - Fax:763-424-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01666101Y00000X, 101YM0800X, 101YP2500X, 103K00000X, 133NN1002X
MN01664101Y00000X, 101YM0800X, 101YP2500X, 103K00000X, 133NN1002X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty