Provider Demographics
NPI:1629198965
Name:NORTHWEST RESIDENCE, INC.
Entity Type:Organization
Organization Name:NORTHWEST RESIDENCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLLENDICK WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:763-277-1038
Mailing Address - Street 1:4408 69TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1739
Mailing Address - Country:US
Mailing Address - Phone:763-566-3650
Mailing Address - Fax:763-566-4217
Practice Address - Street 1:4408 69TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1739
Practice Address - Country:US
Practice Address - Phone:763-566-3650
Practice Address - Fax:763-566-4217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN283666100Medicare UPIN