Provider Demographics
NPI:1639250111
Name:CENTER FOR HUMAN DEVELOPMENT OF WHITE BEAR LAKE, INC.
Entity Type:Organization
Organization Name:CENTER FOR HUMAN DEVELOPMENT OF WHITE BEAR LAKE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-426-8191
Mailing Address - Street 1:4505 WHITE BEAR PKWY
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3678
Mailing Address - Country:US
Mailing Address - Phone:651-426-8191
Mailing Address - Fax:651-426-6766
Practice Address - Street 1:4505 WHITE BEAR PKWY
Practice Address - Street 2:SUITE 1800
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3678
Practice Address - Country:US
Practice Address - Phone:651-426-8191
Practice Address - Fax:651-426-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103074OtherUCARE
MN790082100Medicaid