Provider Demographics
NPI:1154601474
Name:11MN
Entity type:Organization
Organization Name:11MN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:MONTEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-237-2616
Mailing Address - Street 1:720 3RD AVE NE
Mailing Address - Street 2:STE 109
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2300
Mailing Address - Country:US
Mailing Address - Phone:360-237-2616
Mailing Address - Fax:360-237-2616
Practice Address - Street 1:720 3RD AVE NE
Practice Address - Street 2:STE 109
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2300
Practice Address - Country:US
Practice Address - Phone:360-237-2616
Practice Address - Fax:360-237-2616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302775251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health