Basic Information
| Provider Information | |||||||||
| NPI: | 1689778912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS HEALTH CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 LINCOLN DRIVE, CBC-2-REV/PE | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554361611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529925691 | ||||||||
| FaxNumber: | 9529926917 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 CHICAGO AVE S | ||||||||
| Address2: | CHILDRENS SPECIALITY CLINIC PSYCHOLOGICAL SERVICES MPLS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128138455 | ||||||||
| FaxNumber: | 6128138263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | BRENDA LU | ||||||||
| AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP AND CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6128136129 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 331018 | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | 331018 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 435247500 | 05 | MN | MEDICAID |