Provider Demographics
NPI:1164711735
Name:NORTH CENTRAL MINISTRY DEVELOPMENT CENTER, INC.
Entity Type:Organization
Organization Name:NORTH CENTRAL MINISTRY DEVELOPMENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ELMER
Authorized Official - Last Name:SUNDBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-636-5120
Mailing Address - Street 1:516 MISSION HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2571
Mailing Address - Country:US
Mailing Address - Phone:651-636-5120
Mailing Address - Fax:651-636-5124
Practice Address - Street 1:516 MISSION HOUSE LN
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-2571
Practice Address - Country:US
Practice Address - Phone:651-636-5120
Practice Address - Fax:651-636-5124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4223103TC0700X
MNLP4114103TC1900X
MNLP0816103TC1900X
MNLP5213103TC1900X
MNMN066271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty