Healthcare Provider Details

I. General information

NPI: 1144038290
Provider Name (Legal Business Name): HENNEPIN AUTISM CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 CEDAR AVE S
MINNEAPOLIS MN
55454-1032
US

IV. Provider business mailing address

405 CEDAR AVE S
MINNEAPOLIS MN
55454-1032
US

V. Phone/Fax

Practice location:
  • Phone: 612-259-7711
  • Fax: 612-545-3760
Mailing address:
  • Phone: 612-286-8091
  • Fax: 612-545-3760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider 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: SULEIMAN M ISSE
Title or Position: CEO
Credential:
Phone: 612-259-7711