Healthcare Provider Details

I. General information

NPI: 1982383188
Provider Name (Legal Business Name): SHENOAH REED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10967 UNIVERSITY AVE NE APT F
BLAINE MN
55434-1993
US

IV. Provider business mailing address

10967 UNIVERSITY AVE NE APT F
BLAINE MN
55434-1993
US

V. Phone/Fax

Practice location:
  • Phone: 612-567-7786
  • Fax: 763-390-0027
Mailing address:
  • Phone: 612-567-7786
  • Fax: 763-390-0027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: SHENOAH JEAN REED
Title or Position: PRESIDENT
Credential:
Phone: 612-567-7786