Organization
TUBMAN
Active
Other names
Chrysalis
Organization subpart
No
Provider details
NPI number
Authorized official
BEVERLY DUSSO (EXECUTIVE DIRECTOR)
(612) 767-6690
Entity
Organization
Contact information
Practice address
4432 CHICAGO AVE S, MINNEAPOLIS, MN 55407-3519
(612) 870-2444
(612) 870-2428
Mailing address
4432 CHICAGO AVE S, MINNEAPOLIS, MN 55407-3519
(612) 870-2444
(612) 870-2428
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
800487-2-MCH
MN
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
800488-3-CDT
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
257080700
—
MN
05
—
575255800
—
MN
01
—
9026CH
BCBS
MN
Enumeration date
03/07/2007
Last updated
11/12/2008
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