Healthcare Provider Details

I. General information

NPI: 1417771213
Provider Name (Legal Business Name): 127 MINISTRIES PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2024
Last Update Date: 11/09/2024
Certification Date: 11/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 JOPLIN ST
MORA MN
55051-6831
US

IV. Provider business mailing address

2136 JOPLIN ST
MORA MN
55051-6831
US

V. Phone/Fax

Practice location:
  • Phone: 320-515-2357
  • Fax: 320-515-2357
Mailing address:
  • Phone: 320-515-2357
  • Fax: 320-515-2357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA LARSEN
Title or Position: DIRECTOR
Credential: LICSW
Phone: 320-515-2357