Provider Demographics
NPI:1093898660
Name:WHITE EARTH BAND OF CHIPPEWA
Entity Type:Organization
Organization Name:WHITE EARTH BAND OF CHIPPEWA
Other - Org Name:WHITE EARTH MENTAL HEALTH PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL TREATMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:NATHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-983-3286
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-0300
Mailing Address - Country:US
Mailing Address - Phone:218-983-3286
Mailing Address - Fax:218-983-4236
Practice Address - Street 1:26246 CRANE RD
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591-9998
Practice Address - Country:US
Practice Address - Phone:218-983-3286
Practice Address - Fax:218-983-4236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN961994100251B00000X, 251S00000X
MN261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN961994100Medicaid