Healthcare Provider Details

I. General information

NPI: 1629930417
Provider Name (Legal Business Name): AVANTA THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 11/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N CEDAR AVE STE 1
OWATONNA MN
55060-2306
US

IV. Provider business mailing address

202 N CEDAR AVE STE 1
OWATONNA MN
55060-2306
US

V. Phone/Fax

Practice location:
  • Phone: 651-370-8791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NASRO SAID HASSAN
Title or Position: N/A
Credential:
Phone: 651-370-8791