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General NPI Number Information
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NPI Number | 1598848939
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Entity Type | Organization
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Legal Business Name | SENIOR RECOVERY PROGRAM
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Dates
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Enumeration Date | 10/21/2006
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Last Update Date | 10/30/2009
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Provider Practice Location Address
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Address Line | 2375 ARIEL AVE.
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City | MAPLEWOOD
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State | MN
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Zip | 55109
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Country | US
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Telephone | 651-773-0473
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Fax |
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Provider Business Mailing Address
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Address Line | 2375 ARIEL AVE.
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City | MAPLEWOOD
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State | MN
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Zip | 55109
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Country | US
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Telephone | 651-773-0473
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Fax | 651-773-9298
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JOHN T. CLAWSON
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Credential |
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Telephone | 651-773-0473
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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 | 808754-3-CDT
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License Number State | MN
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