Provider Demographics
NPI:1750636973
Name:NEW SALEM METAMORPHOSIS ADOLESENT PROGRAM
Entity Type:Organization
Organization Name:NEW SALEM METAMORPHOSIS ADOLESENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HORTENSE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:AA
Authorized Official - Phone:612-250-8799
Mailing Address - Street 1:2507 BRYANT AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2116
Mailing Address - Country:US
Mailing Address - Phone:612-250-8799
Mailing Address - Fax:
Practice Address - Street 1:2507 BRYANT AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2116
Practice Address - Country:US
Practice Address - Phone:612-250-8799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-14
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1061325-1-CDT101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty