Provider Demographics
NPI:1043789357
Name:FAMILY FORENSIC AND CLINICAL CENTER
Entity Type:Organization
Organization Name:FAMILY FORENSIC AND CLINICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-636-5549
Mailing Address - Street 1:2451 HAMLINE AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3104
Mailing Address - Country:US
Mailing Address - Phone:651-335-8219
Mailing Address - Fax:
Practice Address - Street 1:127 COUNTY ROAD C E
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-2376
Practice Address - Country:US
Practice Address - Phone:651-335-8219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty