Organization
KINGDOM IN ACTION
Active
Parent organization
GIVING IN GRACE AT SOULS HARBOR
Organization subpart
Yes
Provider details
NPI number
Legal business name
GIVING IN GRACE AT SOULS HARBOR
Authorized official
REGINALD FITZGERALD LEWIS (EXECUTIVE DIRECTOR)
(952) 933-4808
Entity
Organization
Contact information
Practice address
9500 MINNETONKA BLVD, ST LOUIS PARK, MN 55426-2944
(952) 933-4808
Mailing address
9500 MINNETONKA BLVD, ST LOUIS PARK, MN 55426-2944
(952) 933-4808
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
1075563-2-CDT
MN
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
1075563-2-CDT
MN
101YM0800X
Mental Health Counselor
1075563-2-CDT
MN
101YP1600X
Pastoral Counselor
1075563-2-CDT
MN
103TA0400X
Addiction (Substance Use Disorder) Psychologist
1075563-2-CDT
MN
103TC0700X
Clinical Psychologist
1075563-2-CDT
MN
103TC1900X
Counseling Psychologist
1075563-2-CDT
MN
302F00000X
Exclusive Provider Organization
1075563
MN
Other
Enumeration date
12/15/2014
Last updated
03/06/2017
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