Basic Information
| Provider Information | |||||||||
| NPI: | 1922051325 | ||||||||
| 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: | 7066 STILLWATER BLVD N | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551283937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517775222 | ||||||||
| FaxNumber: | 6512515111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 08/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | EASTWOOD | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6517775222 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 101YM0800X | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 313930 | 01 | MN | VALUE OPTIONS | OTHER | 8461062 | 01 | MN | UNITED BEHAVIORAL HEALTH | OTHER | 1029858 | 01 | MN | PREFERRED ONE | OTHER | 106221 | 01 | MN | PMAP U-CARE | OTHER | 7948557000 | 05 | MN | MEDICAID | 56706HU | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER |