Provider Demographics
NPI:1437636131
Name:779 RIVERSIDE RECOVERY & COUNSELING SERVICES
Entity Type:Organization
Organization Name:779 RIVERSIDE RECOVERY & COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COACH
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKUMBE
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC, LADC
Authorized Official - Phone:612-223-6622
Mailing Address - Street 1:8014 HIGHWAY 55 UNIT 197
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4712
Mailing Address - Country:US
Mailing Address - Phone:612-223-6622
Mailing Address - Fax:
Practice Address - Street 1:4940 W 77TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4805
Practice Address - Country:US
Practice Address - Phone:612-223-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00935101Y00000X, 101YM0800X, 101YP2500X, 103TB0200X, 103TC0700X, 103TP2701X, 261QM0850X, 261QM0855X
MN303344101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty