Healthcare Provider Details

I. General information

NPI: 1376950469
Provider Name (Legal Business Name): TRANSFORMATION HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 74TH AVE NE
FRIDLEY MN
55432-3258
US

IV. Provider business mailing address

1410 S FERRY ST
ANOKA MN
55303-2152
US

V. Phone/Fax

Practice location:
  • Phone: 763-427-7155
  • Fax:
Mailing address:
  • Phone: 763-426-7155
  • Fax: 763-427-6084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number10739571CDT
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CRISTIAN CHIESA
Title or Position: CEO
Credential:
Phone: 763-452-7011