Provider Demographics
NPI:1225308786
Name:GAMBLER'S RELIEF
Entity Type:Organization
Organization Name:GAMBLER'S RELIEF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-224-2990
Mailing Address - Street 1:2960 JUDICIAL RD
Mailing Address - Street 2:210
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5507
Mailing Address - Country:US
Mailing Address - Phone:952-224-2990
Mailing Address - Fax:952-224-2990
Practice Address - Street 1:2960 JUDICIAL RD
Practice Address - Street 2:210
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5507
Practice Address - Country:US
Practice Address - Phone:952-224-2990
Practice Address - Fax:952-224-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302633101YA0400X
101YA0400X
MNLP3228103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty