Healthcare Provider Details

I. General information

NPI: 1285400606
Provider Name (Legal Business Name): MENTALFITNESSCONNECTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 S TIMBER RDG
FRIDLEY MN
55432-4742
US

IV. Provider business mailing address

1512 S TIMBER RDG
FRIDLEY MN
55432-4742
US

V. Phone/Fax

Practice location:
  • Phone: 612-478-8040
  • Fax:
Mailing address:
  • Phone: 612-478-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RACHEL JEAN BACKLUND
Title or Position: OWNER
Credential: MA, LADC, LPCC
Phone: 612-478-8040