Provider Demographics
NPI:1629117452
Name:AMETHYST COUNSELING SERVICES, INC.
Entity Type:Organization
Organization Name:AMETHYST COUNSELING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORIDANATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:JON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:651-633-4532
Mailing Address - Street 1:1405 SILVER LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-9301
Mailing Address - Country:US
Mailing Address - Phone:651-633-4532
Mailing Address - Fax:651-633-9311
Practice Address - Street 1:1405 SILVER LAKE RD NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-9301
Practice Address - Country:US
Practice Address - Phone:651-633-4532
Practice Address - Fax:651-633-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN820357100324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN97081OtherPREFERREDONE
MN8443304OtherUBH
MN820357100Medicaid
MN18676OtherHEALTHPARTNERS
MN4269AMOtherBLUE CROSS
MN101961OtherUCARE
MN8460134OtherUBH
MN8460135OtherUBH