Provider Demographics
NPI:1558348078
Name:RIVER CITY MENTAL HEALTH CLINIC, P.A.
Entity Type:Organization
Organization Name:RIVER CITY MENTAL HEALTH CLINIC, P.A.
Other - Org Name:RIVER CITY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-312-4569
Mailing Address - Street 1:1360 ENERGY PARK DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5276
Mailing Address - Country:US
Mailing Address - Phone:651-646-8985
Mailing Address - Fax:651-646-3959
Practice Address - Street 1:1360 ENERGY PARK DR
Practice Address - Street 2:SUITE 340
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5276
Practice Address - Country:US
Practice Address - Phone:651-646-8985
Practice Address - Fax:651-646-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN85234OtherHEALTH PARTNERS
MN41G99RIOtherBCBS MN
MN42G12RIOtherBCBS MN
MN98534OtherPERFERRED ONE
MN155441700Medicaid
MN42G08RIOtherBCBS MN
MN98534OtherPERFERRED ONE