Basic Information
| Provider Information | |||||||||
| NPI: | 1528129574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANVAS HEALTH, INC. | ||||||||
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| OtherOrganizationName: | HUMAN SERVICES, INC. IN WASHINGTON COUNTY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7066 STILLWATER BLVD N | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551283937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517775222 | ||||||||
| FaxNumber: | 6512515111 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 11TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | FOREST LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550251850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512515220 | ||||||||
| FaxNumber: | 6512515279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | EASTWOOD | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6517775222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D., MPA, LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 801109 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 353302600 | 05 | MN | MEDICAID |