1205904612 NPI number — PORT OF CROW WING COUNTY, INC

Table of Contents

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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