Provider Demographics
NPI:1659662971
Name:MENTAL HEALTH UNLIMINTED
Entity Type:Organization
Organization Name:MENTAL HEALTH UNLIMINTED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST/CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:OTTUM
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:952-451-1547
Mailing Address - Street 1:6053 HUDSON RD
Mailing Address - Street 2:STE 150
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1015
Mailing Address - Country:US
Mailing Address - Phone:952-451-1547
Mailing Address - Fax:
Practice Address - Street 1:6053 HUDSON RD
Practice Address - Street 2:STE 150
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1015
Practice Address - Country:US
Practice Address - Phone:952-451-1547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN180101041C0700X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1659506525OtherMN MEDICAL ASSISTANCE
MN1740440015OtherPSYCHOTHERAPIST