Provider Demographics
NPI:1073098810
Name:NORTHEAST YOUTH & FAMILY SERVICES
Entity Type:Organization
Organization Name:NORTHEAST YOUTH & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PAQUET
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:651-379-3443
Mailing Address - Street 1:3490 LEXINGTON AVE N STE 205
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8044
Mailing Address - Country:US
Mailing Address - Phone:651-486-3808
Mailing Address - Fax:651-486-3858
Practice Address - Street 1:1280 N BIRCH LAKE BLVD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-6708
Practice Address - Country:US
Practice Address - Phone:651-429-8544
Practice Address - Fax:651-407-5301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST YOUTH & FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA880726400OtherUPI