MEDICARE: STATE OF MINNESOTA DHS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1396617098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF MINNESOTA DHS

Provider Business Mailing Address
First Line	:	3200 LABORE RD
Second Line	:
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5186
Country	:	US
Telephone Number	:	651-539-7200
Fax Number	:	651-431-7505

Provider Business Practice Location Address
First Line	:	10101 1ST AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-4907
Country	:	US
Telephone Number	:	952-948-2040
Fax Number	:

Authorized Official
Title or Position	:	SKILLS DEVELOPMENT SPECIALIST
Name	:	DENISHA J ANDERSON
Credential	:
Telephone Number	:	952-948-2040

Provider Enumeration Date	:	09/22/2025
Last Update Date	:	09/22/2025

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Directions to “STATE OF MINNESOTA DHS ” Practice Location

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