1659662971 NPI number — MENTAL HEALTH UNLIMINTED

Table of content: (NPI 1659662971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659662971 NPI number — MENTAL HEALTH UNLIMINTED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENTAL HEALTH UNLIMINTED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659662971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6053 HUDSON RD
Provider Second Line Business Mailing Address:
STE 150
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-1015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-451-1547
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6053 HUDSON RD
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-1015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-451-1547
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OTTUM
Authorized Official First Name:
JAMISON
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
PSYCHOTHERAPIST/CLINIC DIRECTOR
Authorized Official Telephone Number:
952-451-1547

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  18010 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1659506525 . This is a "MN MEDICAL ASSISTANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1740440015 . This is a "PSYCHOTHERAPIST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".