{
"Npi": {
"NPI": "1417771551",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "WATCH INTERNATIONAL FOR THE SECURITY OF HUMANITY (THE WISH CENTER)",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6248 LAKELAND AVE N STE 210",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MINNEAPOLIS",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55428-2989",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "763-447-1063",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "6248 LAKELAND AVE N STE 210",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MINNEAPOLIS",
"PracticeLocationAddressStateName": "MN",
"PracticeLocationAddressPostalCode": "55428-2989",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "763-447-1063",
"PracticeLocationAddressFaxNumber": "763-592-8099",
"EnumerationDate": "11/14/2024",
"LastUpdateDate": "12/02/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GRAY",
"AuthorizedOfficialFirstName": "EDMOND",
"AuthorizedOfficialMiddleName": "REMIE",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MA",
"AuthorizedOfficialTelephoneNumber": "763-447-1063",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "251B00000X",
"TaxonomyName": "Case Management Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}