Provider Demographics
NPI:1114539434
Name:NORTHWAY ACADEMY, INC.
Entity Type:Organization
Organization Name:NORTHWAY ACADEMY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP & SR ASST GC
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:RODENBERG-ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-836-2234
Mailing Address - Street 1:6600 FRANCE AVE S STE 350
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1810
Mailing Address - Country:US
Mailing Address - Phone:952-563-2207
Mailing Address - Fax:952-922-6885
Practice Address - Street 1:19437 EVANS STREET NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1074
Practice Address - Country:US
Practice Address - Phone:320-290-0693
Practice Address - Fax:952-945-4918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health