Healthcare Provider Details

I. General information

NPI: 1649538349
Provider Name (Legal Business Name): DREAMING TREE BEHAVIORAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4708 MANOR BROOK DR NW
ROCHESTER MN
55901-3176
US

IV. Provider business mailing address

4708 MANOR BROOK DR NW
ROCHESTER MN
55901-3176
US

V. Phone/Fax

Practice location:
  • Phone: 507-272-5646
  • Fax: 507-775-6103
Mailing address:
  • Phone:
  • Fax: 507-775-6103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1-107927
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number1669745105
License Number State

VIII. Authorized Official

Name: AMY K MAHLUM
Title or Position: CEO
Credential: MS, BCBA
Phone: 507-272-5646