Healthcare Provider Details

I. General information

NPI: 1114710332
Provider Name (Legal Business Name): SUPPORTIVE HOUSING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 JAMES AVE N
MINNEAPOLIS MN
55411-1932
US

IV. Provider business mailing address

2301 JAMES AVE N
MINNEAPOLIS MN
55411-1932
US

V. Phone/Fax

Practice location:
  • Phone: 612-800-1897
  • Fax:
Mailing address:
  • Phone: 612-800-1897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GADA WAKO
Title or Position: DIRECTOR
Credential:
Phone: 612-800-1897