Provider Demographics
NPI:1962509364
Name:HOPE HOUSE OF ITASCA COUNTY, INC.
Entity Type:Organization
Organization Name:HOPE HOUSE OF ITASCA COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MARCHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-327-9944
Mailing Address - Street 1:2002 CROMELL DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3571
Mailing Address - Country:US
Mailing Address - Phone:218-326-1443
Mailing Address - Fax:218-326-4390
Practice Address - Street 1:2002 CROMELL DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3571
Practice Address - Country:US
Practice Address - Phone:218-326-1443
Practice Address - Fax:218-326-4390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801078324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN798555000Medicaid