Healthcare Provider Details

I. General information

NPI: 1265314900
Provider Name (Legal Business Name): EPIC WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11065 UNIVERSITY AVE NE APT E
BLAINE MN
55434-1999
US

IV. Provider business mailing address

11065 UNIVERSITY AVE NE APT E
BLAINE MN
55434-1999
US

V. Phone/Fax

Practice location:
  • Phone: 763-347-0981
  • Fax:
Mailing address:
  • Phone: 763-347-0981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: FANUSA HEYDAR SHARIF
Title or Position: CEO
Credential:
Phone: 763-347-0981