Basic Information
| Provider Information | |||||||||
| NPI: | 1194790733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUMAN DEVELOPMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284491 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284491 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | HATFIELD | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2187284491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSW, LICSW, LADC | ||||||||
| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 744755800 | 05 | MN | MEDICAID |