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General NPI Number Information
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NPI Number | 1225308786
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Entity Type | Organization
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Legal Business Name | GAMBLER'S RELIEF
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Dates
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Enumeration Date | 12/30/2011
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Last Update Date | 12/30/2011
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Provider Practice Location Address
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Address Line | 2960 JUDICIAL RD 210
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City | BURNSVILLE
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State | MN
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Zip | 55337-5507
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Country | US
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Telephone | 952-224-2990
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Fax | 952-224-2990
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Provider Business Mailing Address
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Address Line | 2960 JUDICIAL RD 210
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City | BURNSVILLE
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State | MN
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Zip | 55337-5507
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Country | US
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Telephone | 952-224-2990
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Fax | 952-224-2990
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Authorized Official
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Title or Position | BUSINESS OFFICE MANAGER
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Name | RUTH RUSSO
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Credential |
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Telephone | 952-224-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 302633
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP3228
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License Number State | MN
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