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General NPI Number Information
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NPI Number | 1801149505
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Entity Type | Organization
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Legal Business Name | VALHALLA PLACE, LLC
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Dates
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Enumeration Date | 10/18/2012
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Last Update Date | 12/23/2024
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Provider Practice Location Address
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Address Line | 2807 BROOKDALE DR
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City | BROOKLYN PARK
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State | MN
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Zip | 55444-1844
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Country | US
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Telephone | 651-925-8200
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Fax |
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Provider Business Mailing Address
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Address Line | 6043 HUDSON RD 220
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City | WOODBURY
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State | MN
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Zip | 55125-1018
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Country | US
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Telephone | 651-925-8200
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JAY HIGHAM
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Credential |
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Telephone | 214-365-6112
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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 | 15731
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number | 1063405
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License Number State | MN
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