Healthcare Provider Details

I. General information

NPI: 1831992999
Provider Name (Legal Business Name): GRANDMA'S HOUSE CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 NEVADA AVE N
NEW HOPE MN
55427-1340
US

IV. Provider business mailing address

4016 NEVADA AVE N
MINNEAPOLIS MN
55427-1340
US

V. Phone/Fax

Practice location:
  • Phone: 218-531-3846
  • Fax:
Mailing address:
  • Phone: 218-531-3846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JESSICA GILBEUNA
Title or Position: PROGRAM DIRECTOR
Credential: RN
Phone: 218-671-0959