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NPI Code Detail

MEDICARE: SUPPORTIVE LIVING SERVICES, INC.

MEDICARE: SUPPORTIVE LIVING SERVICES, INC.
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
1251S00000XCommunity/Behavioral Health AgencyMN

General Provider Information

NPI Number : 1346374063
Entity Type Code : Organization
Provider Name (Legal Business Name) : SUPPORTIVE LIVING SERVICES, INC.
Provider Business Mailing Address
First Line : 5615 BROOKLYN BLVD STE 200
Second Line :
City : BROOKLYN CENTER
State : MN
Zip : 55429-3086
Country : US
Telephone Number : 763-537-6612
Fax Number :
Provider Business Practice Location Address
First Line : 5615 BROOKLYN BLVD STE 200
Second Line :
City : BROOKLYN CENTER
State : MN
Zip : 55429-3086
Country : US
Telephone Number : 763-537-6612
Fax Number :
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : DIANE M OLLENDICK WRIGHT
Credential : LICSW
Telephone Number : 763-277-1038
Provider Enumeration Date : 03/15/2007
Last Update Date : 05/24/2013

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Directions to “SUPPORTIVE LIVING SERVICES, INC. ” Practice Location

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