Healthcare Provider Details

I. General information

NPI: 1669047585
Provider Name (Legal Business Name): NORTHWAY ACADEMY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 GLENN RD NW
ALEXANDRIA MN
56308-4007
US

IV. Provider business mailing address

6600 FRANCE AVE S STE 350
EDINA MN
55435-1810
US

V. Phone/Fax

Practice location:
  • Phone: 320-290-0693
  • Fax: 952-945-4918
Mailing address:
  • Phone: 952-563-2207
  • Fax: 952-922-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY PATRICIA RODENBERG-ROBERTS
Title or Position: VP & SR ASST GC
Credential:
Phone: 952-836-2234