Basic Information
| Provider Information | |||||||||
| NPI: | 1164610986 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHLAND COUNSELING CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 SE 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557443615 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 215 SE 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557443615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183261274 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 10/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | K. | ||||||||
| AuthorizedOfficialMiddleName: | GREG | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2183260099 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 72560NO | 01 | MN | BCBS | OTHER |