MEDICARE: AGAPE PSYCHIATRIC SERVICES LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1528863131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPE PSYCHIATRIC SERVICES LLC

Provider Business Mailing Address
First Line	:	10913 131ST AVE N
Second Line	:
City	:	CHAMPLIN
State	:	MN
Zip	:	55316-1143
Country	:	US
Telephone Number	:	610-202-6770
Fax Number	:

Provider Business Practice Location Address
First Line	:	10913 131ST AVE N
Second Line	:
City	:	CHAMPLIN
State	:	MN
Zip	:	55316-1143
Country	:	US
Telephone Number	:	610-202-6770
Fax Number	:

Authorized Official
Title or Position	:	CEO/NURSE PRACTITIONER
Name	:	PENNINAH OBWAYA
Credential	:
Telephone Number	:	610-202-6770

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	02/17/2025

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