Provider Demographics
NPI:1831413921
Name:NEW BEGINNINGS AT WAVERLY, LLC
Entity type:Organization
Organization Name:NEW BEGINNINGS AT WAVERLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLELLAND
Authorized Official - Middle Name:PIERRE
Authorized Official - Last Name:GILCHRIST
Authorized Official - Suffix:
Authorized Official - Credentials:MS LADC
Authorized Official - Phone:763-658-5800
Mailing Address - Street 1:109 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:MN
Mailing Address - Zip Code:55390-5517
Mailing Address - Country:US
Mailing Address - Phone:763-658-5800
Mailing Address - Fax:763-658-4128
Practice Address - Street 1:109 N SHORE DR
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:MN
Practice Address - Zip Code:55390-5517
Practice Address - Country:US
Practice Address - Phone:763-658-5800
Practice Address - Fax:763-658-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1003743-5 CDT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1003743-5 CDTOtherMN DEPARTMENT OF HEALTH
MN670005500Medicaid