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General NPI Number Information
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NPI Number | 1548539786
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Entity Type | Organization
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Legal Business Name | HOPE VILLAGE, LLC
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Dates
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Enumeration Date | 12/16/2011
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Last Update Date | 12/16/2011
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Provider Practice Location Address
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Address Line | 6043 HUDSON RD SUITE 372
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City | WOODBURY
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State | MN
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Zip | 55125-1018
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Country | US
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Telephone | 651-714-9171
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Fax | 651-714-9176
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Provider Business Mailing Address
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Address Line | 6043 HUDSON RD SUITE 372
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City | WOODBURY
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State | MN
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Zip | 55125-1018
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Country | US
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Telephone | 651-714-9171
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Fax | 651-714-9176
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. ROSELLA COLLINS-PUOCH
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Credential | LICSW
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Telephone | 612-669-9202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 18674
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License Number State | MN
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