Healthcare Provider Details

I. General information

NPI: 1295866911
Provider Name (Legal Business Name): TUBMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4432 CHICAGO AVE S
MINNEAPOLIS MN
55407-3519
US

IV. Provider business mailing address

4432 CHICAGO AVE S
MINNEAPOLIS MN
55407-3519
US

V. Phone/Fax

Practice location:
  • Phone: 612-870-2444
  • Fax: 612-870-2428
Mailing address:
  • Phone: 612-870-2444
  • Fax: 612-870-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number800487-2-MCH
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number800488-3-CDT
License Number StateMN

VIII. Authorized Official

Name: BEVERLY DUSSO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-767-6690