Provider Demographics
NPI:1467197426
Name:MINO-MIIKANAANG BIMA'ADOO
Entity Type:Organization
Organization Name:MINO-MIIKANAANG BIMA'ADOO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TASHINA
Authorized Official - Middle Name:LERAE
Authorized Official - Last Name:BRANCHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:LSW, LADC, CADCII
Authorized Official - Phone:218-368-2472
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-1105
Mailing Address - Country:US
Mailing Address - Phone:218-368-2472
Mailing Address - Fax:
Practice Address - Street 1:14468 LITTLE ROCK ST.
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-368-2472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty