MEDICARE: AMETHYST COUNSELING SERVICES, INC.

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	324500000X	Substance Abuse Rehabilitation Facility	820357100	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	97081	OTHER	MN	PREFERREDONE
2	8443304	OTHER	MN	UBH
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	18676	OTHER	MN	HEALTHPARTNERS
5	4269AM	OTHER	MN	BLUE CROSS
6	101961	OTHER	MN	UCARE
7	8460134	OTHER	MN	UBH
8	8460135	OTHER	MN	UBH

General Provider Information

NPI Number	:	1629117452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMETHYST COUNSELING SERVICES, INC.

Provider Business Mailing Address
First Line	:	1405 SILVER LAKE RD NW
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9301
Country	:	US
Telephone Number	:	651-633-4532
Fax Number	:	651-633-9311

Provider Business Practice Location Address
First Line	:	1405 SILVER LAKE RD NW
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9301
Country	:	US
Telephone Number	:	651-633-4532
Fax Number	:	651-633-9311

Authorized Official
Title or Position	:	PROGRAM COORIDANATOR
Name	:	TAMMY JON JOHNSON
Credential	:	LADC
Telephone Number	:	651-633-4532

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	04/28/2008

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