Provider Demographics
NPI:1730490665
Name:TUBMAN
Entity Type:Organization
Organization Name:TUBMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEMICAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:612-870-2447
Mailing Address - Street 1:4432 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4432 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3519
Practice Address - Country:US
Practice Address - Phone:612-870-2447
Practice Address - Fax:612-870-2428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302879251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health