Provider Demographics
NPI:1023832938
Name:PREMIERE MENTAL HEALTH LLC
Entity type:Organization
Organization Name:PREMIERE MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRINCESS
Authorized Official - Middle Name:KOU
Authorized Official - Last Name:GEHYIGON-WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-913-8125
Mailing Address - Street 1:360 SHERMAN ST STE 290
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2564
Mailing Address - Country:US
Mailing Address - Phone:763-913-8125
Mailing Address - Fax:
Practice Address - Street 1:360 SHERMAN ST STE 290
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2564
Practice Address - Country:US
Practice Address - Phone:763-913-8125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center