Healthcare Provider Details

I. General information

NPI: 1477330330
Provider Name (Legal Business Name): DIVERSE MENTAL HEALTH RESPONSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 QUEEN AVE N
MINNEAPOLIS MN
55411-2926
US

IV. Provider business mailing address

9216 WHITE OAKS TRL
CHAMPLIN MN
55316-2675
US

V. Phone/Fax

Practice location:
  • Phone: 651-425-1614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. XENG Y PHA
Title or Position: OWNER
Credential: LICSW
Phone: 651-425-1614