MEDICARE: PHYLLIS WHEATLEY COMMUNITY CENTER, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1669998357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYLLIS WHEATLEY COMMUNITY CENTER, INC.

Provider Business Mailing Address
First Line	:	1301 10TH AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-4406
Country	:	US
Telephone Number	:	612-374-4342
Fax Number	:	612-377-9089

Provider Business Practice Location Address
First Line	:	1301 10TH AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-4406
Country	:	US
Telephone Number	:	612-374-4342
Fax Number	:	612-377-9089

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. BRIANNA MICHELLE MILLER
Credential	:
Telephone Number	:	612-374-4342

Provider Enumeration Date	:	08/15/2017
Last Update Date	:	07/21/2022

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