Healthcare Provider Details

I. General information

NPI: 1346982402
Provider Name (Legal Business Name): ONEFAMILY THERAPY & WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2022
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 COUNTY ROAD B W STE 101
ROSEVILLE MN
55113-4037
US

IV. Provider business mailing address

1751 COUNTY ROAD B W STE 101
ROSEVILLE MN
55113-4037
US

V. Phone/Fax

Practice location:
  • Phone: 612-236-4686
  • Fax: 763-201-7979
Mailing address:
  • Phone: 612-236-4686
  • Fax: 763-201-7979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ILYAS A ABDIKADIR
Title or Position: OWNER
Credential: LPCC
Phone: 612-615-6848