NPIMap

Organization Active NPI

Northwest Residence, Inc.

  • Mental Illness Community Based Residential Treatment Facility
  • Brooklyn Center, MN
National Provider Identifier
1629198965
Registry record updated May 24, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Illness Community Based Residential Treatment FacilityTaxonomy code 320800000X
Legal business name
NORTHWEST RESIDENCE, INC.
Practice address
4408 69TH Ave N
Brooklyn Center, MN 55429-1739
Phone
(763) 566-3650
Fax
(763) 566-4217
NPI assigned
Mar 30, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 24, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Diane M Ollendick Wright, LICSW
Title
Executive Director
Phone
(763) 277-1038

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X
Mental Illness Community Based Residential Treatment Facility 320800000X Primary

Addresses

Primary practice location

4408 69TH Ave N
Brooklyn Center, MN 55429-1739

Mailing address

4408 69TH Ave N
Brooklyn Center, MN 55429-1739
Phone (763) 566-3650

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175212800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1369353600000",
    "number": "1629198965",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4408 69TH AVE N",
            "city": "BROOKLYN CENTER",
            "state": "MN",
            "postal_code": "554291739",
            "telephone_number": "763-566-3650",
            "fax_number": "763-566-4217"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4408 69TH AVE N",
            "city": "BROOKLYN CENTER",
            "state": "MN",
            "postal_code": "554291739",
            "telephone_number": "763-566-3650",
            "fax_number": "763-566-4217"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHWEST RESIDENCE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-30",
        "last_updated": "2013-05-24",
        "status": "A",
        "authorized_official_last_name": "OLLENDICK WRIGHT",
        "authorized_official_first_name": "DIANE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "763-277-1038",
        "authorized_official_credential": "LICSW"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Brooklyn Center, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.