Provider Demographics
NPI:1457022501
Name:THERESAS HOME LLC
Entity Type:Organization
Organization Name:THERESAS HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:NGONGANG
Authorized Official - Last Name:OGUNYEMI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:763-291-4288
Mailing Address - Street 1:9985 AUSTIN ST NE
Mailing Address - Street 2:
Mailing Address - City:CIRCLE PINES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-2412
Mailing Address - Country:US
Mailing Address - Phone:763-291-4288
Mailing Address - Fax:
Practice Address - Street 1:224 2ND AVE S
Practice Address - Street 2:
Practice Address - City:SOUTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-2346
Practice Address - Country:US
Practice Address - Phone:763-291-4288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness