Provider Demographics
NPI:1619229754
Name:NORTHERN LIGHTS PSYCHOLOGICAL SERVICES P.A.
Entity Type:Organization
Organization Name:NORTHERN LIGHTS PSYCHOLOGICAL SERVICES P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:507-828-1433
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56586-0003
Mailing Address - Country:US
Mailing Address - Phone:507-828-1433
Mailing Address - Fax:
Practice Address - Street 1:1010 FRONTIER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1023
Practice Address - Country:US
Practice Address - Phone:507-828-1433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-14
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4330251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6178609OtherMEDICA
MN589175200Medicaid
978T6PSOtherBCBS OF MN
MN680001862Medicare UPIN