Provider Demographics
NPI:1578574471
Name:CYPRESS GROVE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:CYPRESS GROVE BEHAVIORAL HEALTH LLC
Other - Org Name:MERIDIAN BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-326-7575
Mailing Address - Street 1:550 MAIN STREET
Mailing Address - Street 2:SUITE 250, CONTRACTING/CREDENTIALING
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:612-326-7575
Mailing Address - Fax:612-454-2430
Practice Address - Street 1:414 PINE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6228
Practice Address - Country:US
Practice Address - Phone:318-699-8819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159664125Medicaid
LA1709581Medicaid
AR159664125Medicaid