Basic Information
| Provider Information | |||||||||
| NPI: | 1831413921 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW BEGINNINGS AT WAVERLY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 109 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553905517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636585800 | ||||||||
| FaxNumber: | 7636584128 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553905517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636585800 | ||||||||
| FaxNumber: | 7636584128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2010 | ||||||||
| LastUpdateDate: | 03/18/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILCHRIST | ||||||||
| AuthorizedOfficialFirstName: | CLELLAND | ||||||||
| AuthorizedOfficialMiddleName: | PIERRE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7636585800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS LADC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1003743-5 CDT | MN | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1003743-5 CDT | 01 | MN | MN DEPARTMENT OF HEALTH | OTHER | 670005500 | 05 | MN | MEDICAID |