Healthcare Provider Details

I. General information

NPI: 1396322293
Provider Name (Legal Business Name): CROSSROADS AFTERCARE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 METRO BLVD STE 100
EDINA MN
55439-2145
US

IV. Provider business mailing address

7250 METRO BLVD STE 100
EDINA MN
55439-2145
US

V. Phone/Fax

Practice location:
  • Phone: 612-200-9870
  • Fax:
Mailing address:
  • Phone: 612-200-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JOHN RUNDQUIST
Title or Position: EXECUTIVE DIRECTOR
Credential: LADC
Phone: 612-374-0506