Healthcare Provider Details

I. General information

NPI: 1700469640
Provider Name (Legal Business Name): NORTHERN TRANQUILITY MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 W LAKE ST
CHISHOLM MN
55719-1817
US

IV. Provider business mailing address

12 W LAKE ST
CHISHOLM MN
55719-1817
US

V. Phone/Fax

Practice location:
  • Phone: 218-296-0688
  • Fax: 844-921-1071
Mailing address:
  • Phone: 218-254-0101
  • Fax: 844-921-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MELISSA SUE BRUSACORAM
Title or Position: OWNER, CEO, APRN-CNP, PMHNP-BC
Credential: APRN-CNP
Phone: 218-254-0101