Provider Demographics
NPI:1275914582
Name:CHILD PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:CHILD PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN-PSYCHIATRY
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCHORN-RHODA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CPNP,CNS
Authorized Official - Phone:320-597-4109
Mailing Address - Street 1:22194 GREAT NORTHERN DR
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:MN
Mailing Address - Zip Code:56320-8811
Mailing Address - Country:US
Mailing Address - Phone:320-597-4109
Mailing Address - Fax:
Practice Address - Street 1:22194 GREAT NORTHERN DR
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:MN
Practice Address - Zip Code:56320-8811
Practice Address - Country:US
Practice Address - Phone:320-597-4109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR126869-2251S00000X
MN2009002720251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN817825900OtherMEDICARE ID TPYE UNSPECIFIED
MN22G39SCMedicare UPIN