MEDICARE: MERGING RIVERS LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1649091588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERGING RIVERS LLC

Provider Business Mailing Address
First Line	:	4905 31ST AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55417-1403
Country	:	US
Telephone Number	:	952-900-2749
Fax Number	:	952-333-7493

Provider Business Practice Location Address
First Line	:	2420 CLEVELAND AVE N
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-2727
Country	:	US
Telephone Number	:	952-900-2749
Fax Number	:	952-333-7493

Authorized Official
Title or Position	:	OWNER
Name	:	ALEXANDER SULLIVAN
Credential	:	LICSW
Telephone Number	:	952-900-2749

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	01/30/2025

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