Healthcare Provider Details

I. General information

NPI: 1750158556
Provider Name (Legal Business Name): HARBOR OF HOPE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 PORTLAND AVE APT 1807
MINNEAPOLIS MN
55404-1268
US

IV. Provider business mailing address

929 PORTLAND AVE APT 1807
MINNEAPOLIS MN
55404-1268
US

V. Phone/Fax

Practice location:
  • Phone: 571-477-7725
  • Fax:
Mailing address:
  • Phone: 571-477-7725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HIETHAM ZEMAM
Title or Position: DIRECTOR
Credential:
Phone: 571-477-7725