Provider Demographics
NPI:1700567682
Name:MINNESOTA TEEN CHALLENGE, INC
Entity Type:Organization
Organization Name:MINNESOTA TEEN CHALLENGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAULIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-373-3366
Mailing Address - Street 1:740 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3862
Mailing Address - Country:US
Mailing Address - Phone:612-373-3366
Mailing Address - Fax:
Practice Address - Street 1:625 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1663
Practice Address - Country:US
Practice Address - Phone:612-373-3366
Practice Address - Fax:612-333-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder