=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669361499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAR THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2025
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4470 W 78TH STREET CIR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-713-7467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8200 HUMBOLDT AVE S # 402
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-1433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-713-7467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MOUKTAR BOURALEH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-713-7467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------