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General NPI Number Information
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NPI Number | 1669285524
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Entity Type | Organization
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Legal Business Name | WATERSHED BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 01/27/2025
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 2429 UNIVERSITY AVE W
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City | SAINT PAUL
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State | MN
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Zip | 55114-1541
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Country | US
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Telephone | 612-703-9413
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Fax |
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Provider Business Mailing Address
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Address Line | 2429 UNIVERSITY AVE W
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City | SAINT PAUL
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State | MN
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Zip | 55114-1541
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Country | US
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Telephone | 612-703-9413
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BISHAR A YUSUF
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Credential |
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Telephone | 612-703-9413
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0401X
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Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
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License Number |
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License Number State |
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