Provider Demographics
NPI:1053700740
Name:ABIJAH'S HOPE
Entity type:Organization
Organization Name:ABIJAH'S HOPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:320-219-3192
Mailing Address - Street 1:12058 55TH ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2029
Mailing Address - Country:US
Mailing Address - Phone:715-379-1370
Mailing Address - Fax:
Practice Address - Street 1:12058 55TH ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-2029
Practice Address - Country:US
Practice Address - Phone:715-379-1370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-18
Last Update Date:2015-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21186251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health