Basic Information
| Provider Information | |||||||||
| NPI: | 1164556544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVALON PROGRAMS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW BEGINNINGS MINNESOTA AT EAGAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3470 WASHINGTON AVE SUITE 165 | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
| FaxNumber: | 6516313231 | ||||||||
| Practice Location | |||||||||
| Address1: | 3740 WASHINGTON DRIVE # 165 | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514542833 | ||||||||
| FaxNumber: | 6514542972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ASPER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR CONTRACTING,CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6124542046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 324500000X | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.