=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053198754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON MENTAL HEALTH COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2023
-----------------------------------------------------
Last Update Date | 09/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 607 COUNTY ROAD 10 NE STE 200
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55434-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-465-1869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 607 COUNTY ROAD 10 NE STE 200
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55434-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | CHRISTOPHER COLEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-465-1869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------