Provider Demographics
NPI:1093926099
Name:INDEPENDENT DISABILITY SERVICES
Entity Type:Organization
Organization Name:INDEPENDENT DISABILITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DEROSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-632-2674
Mailing Address - Street 1:1201 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3342
Practice Address - Country:US
Practice Address - Phone:320-632-2674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1047172320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities