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General NPI Number Information
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NPI Number | 1437636131
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Entity Type | Organization
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Legal Business Name | 779 RIVERSIDE RECOVERY & COUNSELING SERVICES
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Dates
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Enumeration Date | 07/25/2018
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Last Update Date | 07/25/2018
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Provider Practice Location Address
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Address Line | 4940 W 77TH ST
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City | EDINA
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State | MN
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Zip | 55435-4805
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Country | US
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Telephone | 612-223-6622
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Fax |
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Provider Business Mailing Address
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Address Line | 8014 HIGHWAY 55 UNIT 197
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City | GOLDEN VALLEY
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State | MN
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Zip | 55427-4712
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Country | US
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Telephone | 612-223-6622
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Fax |
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Authorized Official
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Title or Position | OWNER / CLINICAL DIRECTOR
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Name | COACH NAKUMBE
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Credential | LPCC, LADC
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Telephone | 612-223-6622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 00935
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 00935
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 00935
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number | 00935
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License Number State | MN
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Taxonomy #5
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 00935
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License Number State | MN
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Taxonomy #6
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number | 00935
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License Number State | MN
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Taxonomy #7
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 00935
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License Number State | MN
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Taxonomy #8
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 00935
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License Number State | MN
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Taxonomy #9
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 303344
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License Number State | MN
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