1205904612 NPI number — PORT OF CROW WING COUNTY, INC

Table of content: (NPI 1205904612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205904612 NPI number — PORT OF CROW WING COUNTY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORT OF CROW WING COUNTY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA LAKES AREA COUNSELING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205904612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 367
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56345-0367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-632-6647
Provider Business Mailing Address Fax Number:
320-639-0014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1906 5TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56345-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-632-6647
Provider Business Practice Location Address Fax Number:
320-632-9525
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAIDER
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
320-639-1425

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 059T5PO . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62-764-39 . This is a "UNITED BEHAVORIAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 131919 . This is a "U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 82364 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 006031300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34B87PO . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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