Provider Demographics
NPI:1083646327
Name:ITASCA PSYCHIATRIC SERVICES INC
Entity Type:Organization
Organization Name:ITASCA PSYCHIATRIC SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-327-2284
Mailing Address - Street 1:25 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2742
Mailing Address - Country:US
Mailing Address - Phone:218-327-2284
Mailing Address - Fax:218-327-3173
Practice Address - Street 1:25 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2742
Practice Address - Country:US
Practice Address - Phone:218-327-2284
Practice Address - Fax:218-327-3173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23479261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)