Provider Demographics
NPI:1609146364
Name:THE SCOTT COUNTY JAIL TREATMENT PROGRAM
Entity Type:Organization
Organization Name:THE SCOTT COUNTY JAIL TREATMENT PROGRAM
Other - Org Name:LOREN E. NOVAK & ASSOCIATES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MILO
Authorized Official - Last Name:WALBERG
Authorized Official - Suffix:
Authorized Official - Credentials:BS, LADC
Authorized Official - Phone:952-447-1117
Mailing Address - Street 1:14162 COMMERCE AVE NE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1480
Mailing Address - Country:US
Mailing Address - Phone:952-447-1117
Mailing Address - Fax:952-447-1116
Practice Address - Street 1:301 FULLER ST S
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1322
Practice Address - Country:US
Practice Address - Phone:952-447-1117
Practice Address - Fax:952-447-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1062184101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty