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General NPI Number Information
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NPI Number | 1730286758
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Entity Type | Organization
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Legal Business Name | MY HOME INC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 420 N 5TH ST SUITE 949
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City | MINNEAPOLIS
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State | MN
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Zip | 55401-1348
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Country | US
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Telephone | 612-343-0661
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Fax | 612-341-8353
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Provider Business Mailing Address
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Address Line | 1010 UNIVERSITY AVE W SUITE 1
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City | SAINT PAUL
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State | MN
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Zip | 55104-4746
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Country | US
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Telephone | 651-659-0359
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Fax | 651-645-1688
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. FARRIS L. GLOVER
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Credential | LADC
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Telephone | 651-659-0359
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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 | 1015883-1-CDT
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License Number State | MN
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