Provider Demographics
NPI:1215692785
Name:MOMENTA MENTAL HEALTH
Entity type:Organization
Organization Name:MOMENTA MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARION
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:651-381-6611
Mailing Address - Street 1:1060 HILLVALE AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5859
Mailing Address - Country:US
Mailing Address - Phone:651-381-6611
Mailing Address - Fax:
Practice Address - Street 1:2179 4TH ST STE 2F
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3041
Practice Address - Country:US
Practice Address - Phone:701-426-8833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1053785691Medicaid