Provider Demographics
NPI:1285057539
Name:MINNESOTA TEEN CHALLENGE, INC.
Entity type:Organization
Organization Name:MINNESOTA TEEN CHALLENGE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREATMENT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, NCAC1
Authorized Official - Phone:507-218-3450
Mailing Address - Street 1:1619 PORTLAND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404
Mailing Address - Country:US
Mailing Address - Phone:612-373-3366
Mailing Address - Fax:612-333-4111
Practice Address - Street 1:1530 ASSISI DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:507-288-3733
Practice Address - Fax:855-288-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No302F00000XManaged Care OrganizationsExclusive Provider Organization