Provider Demographics
NPI:1285074039
Name:BETHANY CHRISTIAN SERVICES OF MINNESOTA
Entity type:Organization
Organization Name:BETHANY CHRISTIAN SERVICES OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:763-553-0344
Mailing Address - Street 1:3131 FERNBROOK LN N STE 204
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5337
Mailing Address - Country:US
Mailing Address - Phone:763-553-0344
Mailing Address - Fax:763-553-0117
Practice Address - Street 1:3131 FERNBROOK LN N STE 204
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5337
Practice Address - Country:US
Practice Address - Phone:763-553-0344
Practice Address - Fax:763-553-0117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHANY CHRISTIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-26
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00747101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty