Provider Demographics
NPI:1770603011
Name:COMMUNITY OPTIONS ST. PAUL, LLC
Entity type:Organization
Organization Name:COMMUNITY OPTIONS ST. PAUL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLLENDICK WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:763-277-1038
Mailing Address - Street 1:1585 RICE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3751
Mailing Address - Country:US
Mailing Address - Phone:651-487-8088
Mailing Address - Fax:651-487-8105
Practice Address - Street 1:1585 RICE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-3751
Practice Address - Country:US
Practice Address - Phone:651-487-8088
Practice Address - Fax:651-487-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331560251S00000X
251X00000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
No251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN837934300Medicare UPIN