=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588489421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSAL BEHAVIORAL AND WELLNESS HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2024
-----------------------------------------------------
Last Update Date | 11/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11670 FOUNTAINS DR STE 200
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55369-7195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-299-4135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11670 FOUNTAINS DR STE 200
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55369-7195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-299-4135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MELANIE ALBERTHA JAPPAH
-----------------------------------------------------
Credential | CNP, DNP, PMHNP
-----------------------------------------------------
Telephone | 763-299-4135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------