Basic Information
| Provider Information | |||||||||
| NPI: | 1629198965 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST RESIDENCE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4408 69TH AVE N | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN CENTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554291739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635663650 | ||||||||
| FaxNumber: | 7635664217 | ||||||||
| Practice Location | |||||||||
| Address1: | 4408 69TH AVE N | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN CENTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554291739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635663650 | ||||||||
| FaxNumber: | 7635664217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 05/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | OLLENDICK WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7632771038 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LICSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.