Healthcare Provider Details

I. General information

NPI: 1760489751
Provider Name (Legal Business Name): FAMILY LIFE MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-4708
US

IV. Provider business mailing address

1930 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-4708
US

V. Phone/Fax

Practice location:
  • Phone: 763-427-7964
  • Fax: 763-427-7976
Mailing address:
  • Phone: 763-427-7964
  • Fax: 763-427-7976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8
License Number StateMN

VIII. Authorized Official

Name: ROBERT SULLIVAN
Title or Position: EXECUTIVE DIRECTOR
Credential: LICSW
Phone: 763-427-7964