Healthcare Provider Details

I. General information

NPI: 1427586296
Provider Name (Legal Business Name): PROJECT FRESH START INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2854 COLUMBUS AVE
MINNEAPOLIS MN
55407-1324
US

IV. Provider business mailing address

PO BOX 7367
MINNEAPOLIS MN
55407-0367
US

V. Phone/Fax

Practice location:
  • Phone: 612-354-7904
  • Fax:
Mailing address:
  • Phone: 651-399-3307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP4593
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number23792
License Number StateMN

VIII. Authorized Official

Name: MS. PAMELS ROBIN ZELLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-399-3307