Provider Demographics
NPI:1568809366
Name:AGATE BAY PROFESSIONALS CHEMICAL HEALTH SERVICES
Entity Type:Organization
Organization Name:AGATE BAY PROFESSIONALS CHEMICAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR & THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW, LADC
Authorized Official - Phone:218-830-8085
Mailing Address - Street 1:227 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 7TH ST
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1530
Practice Address - Country:US
Practice Address - Phone:218-830-8085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health