Healthcare Provider Details

I. General information

NPI: 1831574797
Provider Name (Legal Business Name): MINNESOTA TEEN CHALLENGE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 1ST AVE S
MINNEAPOLIS MN
55408-4407
US

IV. Provider business mailing address

740 E 24TH ST
MINNEAPOLIS MN
55404
US

V. Phone/Fax

Practice location:
  • Phone: 612-373-3366
  • Fax:
Mailing address:
  • Phone: 612-373-3366
  • Fax: 612-333-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SADIE TWITE
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 612-373-3366