Basic Information
| Provider Information | |||||||||
| NPI: | 1114048527 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUMAN DEVELOPMENT CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1401 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284491 | ||||||||
| FaxNumber: | 2187302367 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188794559 | ||||||||
| FaxNumber: | 2188790282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GETCHELL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2187284491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUMAN DEVELOPMENT CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 8534482 | MN | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 744755800 | 05 | MN | MEDICAID | 648518900 | 05 | MN | MEDICAID |