Basic Information
| Provider Information | |||||||||
| NPI: | 1851625156 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH RESOURCES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROJECT HOMEWARD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 762 TRANSFER RD STE 21 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516592900 | ||||||||
| FaxNumber: | 6516457307 | ||||||||
| Practice Location | |||||||||
| Address1: | 762 TRANSFER RD STE 21 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516592900 | ||||||||
| FaxNumber: | 6516457307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2009 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOWELL | ||||||||
| AuthorizedOfficialFirstName: | CARLEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSOC DIR OF ACCTG & BUS SVCS | ||||||||
| AuthorizedOfficialTelephone: | 6513653612 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 650954100 | 05 | MN | MEDICAID |