Healthcare Provider Details

I. General information

NPI: 1174379176
Provider Name (Legal Business Name): SKYLINE MENTAL HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10944 QUANTICO LN N
MAPLE GROVE MN
55369-7527
US

IV. Provider business mailing address

10944 QUANTICO LN N
MAPLE GROVE MN
55369-7527
US

V. Phone/Fax

Practice location:
  • Phone: 763-445-4693
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BUSAYO OKUSANYA
Title or Position: OWNER
Credential:
Phone: 763-268-9552