Healthcare Provider Details

I. General information

NPI: 1871367714
Provider Name (Legal Business Name): 12TH HOUSE HEALING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 AGUIRRE ST APT 232
SAINT PAUL MN
55130-4430
US

IV. Provider business mailing address

650 AGUIRRE ST APT 232
SAINT PAUL MN
55130-4430
US

V. Phone/Fax

Practice location:
  • Phone: 612-584-0902
  • Fax:
Mailing address:
  • Phone: 612-584-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. TAYONNA MARTIA MAYS
Title or Position: CEO
Credential: RN
Phone: 612-584-0902