Provider Demographics
NPI:1396617098
Name:STATE OF MINNESOTA DHS
Entity type:Organization
Organization Name:STATE OF MINNESOTA DHS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SKILLS DEVELOPMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DENISHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-948-2040
Mailing Address - Street 1:3200 LABORE RD
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5186
Mailing Address - Country:US
Mailing Address - Phone:651-539-7200
Mailing Address - Fax:651-431-7505
Practice Address - Street 1:10101 1ST AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4907
Practice Address - Country:US
Practice Address - Phone:952-948-2040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities