Healthcare Provider Details

I. General information

NPI: 1689378655
Provider Name (Legal Business Name): RIVERS MENTAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 WHITE BEAR PKWY STE 226
WHITE BEAR LAKE MN
55110-7660
US

IV. Provider business mailing address

4525 WHITE BEAR PKWY STE 226
WHITE BEAR LAKE MN
55110-7660
US

V. Phone/Fax

Practice location:
  • Phone: 612-702-5432
  • Fax: 612-540-0949
Mailing address:
  • Phone: 612-702-5432
  • 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
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLES ROTH MILLER
Title or Position: OWNER AND THERAPIST
Credential:
Phone: 612-702-5432