Provider Demographics
NPI:1700469640
Name:NORTHERN TRANQUILITY MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:NORTHERN TRANQUILITY MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO, APRN-CNP, PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BRUSACORAM
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:218-254-0101
Mailing Address - Street 1:12 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:CHISHOLM
Mailing Address - State:MN
Mailing Address - Zip Code:55719-1817
Mailing Address - Country:US
Mailing Address - Phone:218-254-0101
Mailing Address - Fax:844-921-1071
Practice Address - Street 1:12 W LAKE ST
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-1817
Practice Address - Country:US
Practice Address - Phone:218-296-0688
Practice Address - Fax:844-921-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health