Provider Demographics
NPI:1518067750
Name:NORTHERN PINES COMMUNITY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:NORTHERN PINES COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICSW
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:MILLICENT
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:320-828-1092
Mailing Address - Street 1:11 1ST ST SE
Mailing Address - Street 2:PO BOX 32
Mailing Address - City:RICE
Mailing Address - State:MN
Mailing Address - Zip Code:56367-8857
Mailing Address - Country:US
Mailing Address - Phone:320-828-1092
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:218-829-3235
Practice Address - Fax:218-829-1368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN160301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty