Healthcare Provider Details

I. General information

NPI: 1285057539
Provider Name (Legal Business Name): MINNESOTA TEEN CHALLENGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 ASSISI DR NW
ROCHESTER MN
55901
US

IV. Provider business mailing address

1619 PORTLAND AVE S
MINNEAPOLIS MN
55404
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-3733
  • Fax: 855-288-8560
Mailing address:
  • Phone: 612-373-3366
  • Fax: 612-333-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL WILLIAM MAHONEY
Title or Position: TREATMENT DIRECTOR
Credential: LADC, NCAC1
Phone: 507-218-3450