MEDICARE: RISE AUTISM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346069093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RISE AUTISM LLC

Provider Business Mailing Address
First Line	:	1913 BROADWAY ST NE STE 100
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2627
Country	:	US
Telephone Number	:	763-353-0763
Fax Number	:	763-260-9898

Provider Business Practice Location Address
First Line	:	1913 BROADWAY ST NE STE 100
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2627
Country	:	US
Telephone Number	:	763-353-0763
Fax Number	:	763-260-9898

Authorized Official
Title or Position	:	OWNER
Name	:	HANI A HASSAN
Credential	:
Telephone Number	:	763-353-0763

Provider Enumeration Date	:	10/09/2024
Last Update Date	:	11/11/2025

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Directions to “RISE AUTISM LLC ” Practice Location

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