Provider Demographics
NPI:1447606959
Name:FDL ADOLESCENT OUTPATIENT TX
Entity Type:Organization
Organization Name:FDL ADOLESCENT OUTPATIENT TX
Other - Org Name:FOND DU LAC RESERVATION BUSINESS COMMITTEE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-879-1227
Mailing Address - Street 1:927 TRETTEL LN
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:927 TRETTEL LN
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1345
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOND DU LAC HUMAN SERVICES DIVISION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-13
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN666815101Medicaid
MN666815100Medicaid
MN8F27F0OtherBCBS AODA
MN5985000001Medicare NSC
MN8F27F0OtherBCBS AODA