Provider Demographics
NPI:1225016306
Name:CENTRAL MINNESOTA MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:CENTRAL MINNESOTA MENTAL HEALTH CENTER
Other - Org Name:NORTHWAY INTENSIVE RESIDENTIAL TREATMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:320-252-5010
Mailing Address - Street 1:1321 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2613
Mailing Address - Country:US
Mailing Address - Phone:320-252-5010
Mailing Address - Fax:320-203-1855
Practice Address - Street 1:1509 24TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1306
Practice Address - Country:US
Practice Address - Phone:320-252-8648
Practice Address - Fax:320-529-4909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801767-1-RMI320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640902400Medicaid