Provider Demographics
NPI:1427410844
Name:KIDSPEACE MESABI ACADEMY
Entity Type:Organization
Organization Name:KIDSPEACE MESABI ACADEMY
Other - Org Name:MESABI COMMUNITY COUNSELING
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:218-258-2311
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:200 WANLESS STREET
Mailing Address - City:BUHL
Mailing Address - State:MN
Mailing Address - Zip Code:55713-0726
Mailing Address - Country:US
Mailing Address - Phone:218-258-2274
Mailing Address - Fax:218-258-2311
Practice Address - Street 1:200 WANLESS STREET
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:MN
Practice Address - Zip Code:55713-0726
Practice Address - Country:US
Practice Address - Phone:218-258-2274
Practice Address - Fax:218-258-2311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDSPEACE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-24
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1075006251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health