Healthcare Provider Details

I. General information

NPI: 1114143989
Provider Name (Legal Business Name): TRANSFORMATION HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2532 N FERRY ST
ANOKA MN
55303-1653
US

IV. Provider business mailing address

1410 S FERRY RD
ANOKA MN
55303-2164
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-4665
  • Fax:
Mailing address:
  • Phone: 763-427-7155
  • Fax: 763-427-6084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number804982-1-CDT
License Number StateMN

VIII. Authorized Official

Name: CRISTIAN J CHIESA
Title or Position: OWNER
Credential:
Phone: 763-427-7155