Healthcare Provider Details

I. General information

NPI: 1700564465
Provider Name (Legal Business Name): OUROBOROS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 THOMAS AVE N
MINNEAPOLIS MN
55411-2349
US

IV. Provider business mailing address

2007 THOMAS AVE N
MINNEAPOLIS MN
55411-2349
US

V. Phone/Fax

Practice location:
  • Phone: 612-708-6057
  • Fax:
Mailing address:
  • Phone: 612-708-6057
  • 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: HILARY MUELLER
Title or Position: OWNER
Credential: LICSW
Phone: 612-552-3881