Provider Demographics
NPI:1356964332
Name:VILLAGE SUPPORT THERAPY AND CONSULTING LLC
Entity type:Organization
Organization Name:VILLAGE SUPPORT THERAPY AND CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:
Authorized Official - Last Name:EROMOBOR
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-223-0099
Mailing Address - Street 1:5424 FREMONT AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-3160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5424 FREMONT AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-3160
Practice Address - Country:US
Practice Address - Phone:612-223-0099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)