Healthcare Provider Details

I. General information

NPI: 1932278538
Provider Name (Legal Business Name): MINNESOTA TEEN CHALLENGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 2ND AVE S
MINNEAPOLIS MN
55403
US

IV. Provider business mailing address

740 E 24TH ST
MINNEAPOLIS MN
55404
US

V. Phone/Fax

Practice location:
  • Phone: 612-373-3366
  • Fax: 612-333-4111
Mailing address:
  • Phone: 612-373-3366
  • Fax: 612-333-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number10090493CDT
License Number StateMN

VIII. Authorized Official

Name: STEPHANIE BEAULIEU
Title or Position: BILLING MANAGER
Credential:
Phone: 763-257-5301