MEDICARE: REBECCA'S PLACE WELLNESS PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	252Y00000X	Early Intervention Provider Agency
3	261QD1600X	Developmental Disabilities Clinic/Center
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1780344713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBECCA'S PLACE WELLNESS PLLC

Provider Business Mailing Address
First Line	:	22 27TH AVE SE UNIT 317
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4237
Country	:	US
Telephone Number	:	651-395-9352
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 27TH AVE SE UNIT 317
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4237
Country	:	US
Telephone Number	:	651-395-9352
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	NAKAMI GREEN
Credential	:	MA
Telephone Number	:	651-395-9352

Provider Enumeration Date	:	12/17/2021
Last Update Date	:	12/17/2021

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