Basic Information
| Provider Information | |||||||||
| NPI: | 1992185524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLAND RECOVERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557444201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183271105 | ||||||||
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| Address1: | 1215 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557444201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183271105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | VIZENOR | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | BETH | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH PRACTITIONER, TRAINEE | ||||||||
| AuthorizedOfficialTelephone: | 218327110524 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 101YM0800X | MN | Y | Agencies | Community/Behavioral Health |
No ID Information.