Basic Information
| Provider Information | |||||||||
| NPI: | 1871627257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVALON PROGRAMS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AVALON - PINE CITY ADD AVALON - STUREON LAKE TO THIS NPI NUMBER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 550 MAIN STREET | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
| FaxNumber: | 6126313231 | ||||||||
| Practice Location | |||||||||
| Address1: | 34079 LAKETOWN ROAD | ||||||||
| Address2: | SUITE #7 | ||||||||
| City: | STURGEON LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183728000 | ||||||||
| FaxNumber: | 2183728002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINSOR | ||||||||
| AuthorizedOfficialFirstName: | CECILIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | TREATMENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6129164876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1034226 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 324500000X | 1034226-2-CDT | MN | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YA0400X | 1054088-1-CDT | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.