Basic Information
| Provider Information | |||||||||
| NPI: | 1578642757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH METRO HUMAN SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MENTAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 166 4TH ST E | ||||||||
| Address2: | |||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513894690 | ||||||||
| FaxNumber: | 6513894691 | ||||||||
| Practice Location | |||||||||
| Address1: | 166 4TH ST E | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551011421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512911979 | ||||||||
| FaxNumber: | 6512917378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | PAUL | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6512561234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 719178200 | 05 | MN | MEDICAID |