Organization
DIVINE LEGACY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LAKESIA AYCOCK (ADMINISTRATION/MHP)
(763) 439-2588
Entity
Organization
Contact information
Practice address
3300 COUNTY ROAD 10 STE 318, BROOKLYN CENTER, MN 55429-3066
(763) 439-2588
Mailing address
3300 COUNTY ROAD 10 STE 318, BROOKLYN CENTER, MN 55429-3066
(763) 439-2588
Taxonomy
Speciality
Code
Description
License number
State
261QC1800X
Corporate Health Clinic/Center
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
Other
Enumeration date
03/18/2019
Last updated
03/18/2019
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