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General NPI Number Information
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NPI Number | 1760489751
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Entity Type | Organization
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Legal Business Name | FAMILY LIFE MENTAL HEALTH CENTER
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Dates
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Enumeration Date | 07/05/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1930 COON RAPIDS BLVD NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-4708
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Country | US
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Telephone | 763-427-7964
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Fax | 763-427-7976
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Provider Business Mailing Address
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Address Line | 1930 COON RAPIDS BLVD NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-4708
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Country | US
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Telephone | 763-427-7964
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Fax | 763-427-7976
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ROBERT SULLIVAN
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Credential | LICSW
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Telephone | 763-427-7964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 8
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License Number State | MN
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