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General NPI Number Information
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NPI Number | 1770436123
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Entity Type | Organization
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Legal Business Name | A WAY OUT SOBER LIVING LLC
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Dates
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Enumeration Date | 02/17/2026
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Last Update Date | 02/17/2026
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Provider Practice Location Address
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Address Line | 22851 MN HIGHWAY 15
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City | DASSEL
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State | MN
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Zip | 55325-3568
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Country | US
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Telephone | 612-916-8770
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Fax | 612-268-4733
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Provider Business Mailing Address
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Address Line | 22851 MN HIGHWAY 15
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City | DASSEL
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State | MN
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Zip | 55325-3568
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Country | US
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Telephone | 612-916-8770
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Fax |
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Authorized Official
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Title or Position | OFFICE SUPPORT
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Name | SHANTHALA MARULASIDDAIAH
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Credential |
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Telephone | 952-221-7228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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