Basic Information
| Provider Information | |||||||||
| NPI: | 1649391053 | ||||||||
| 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: | 2187302367 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187283931 | ||||||||
| FaxNumber: | 2183028728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | HATFIELD | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2187284491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUMAN DEVELOPMENT CENTER | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 8534482 | MN | N | Agencies | Community/Behavioral Health | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 744755800 | 05 | MN | MEDICAID | 186818700 | 05 | MN | MEDICAID |