Provider Demographics
NPI:1639384043
Name:CENTRAL MINNESOTA MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:CENTRAL MINNESOTA MENTAL HEALTH CENTER
Other - Org Name:GREAT RIVER ACT-ST. CLOUD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:320-252-5010
Mailing Address - Street 1:1321 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2613
Mailing Address - Country:US
Mailing Address - Phone:320-252-5010
Mailing Address - Fax:320-203-1855
Practice Address - Street 1:3333 W DIVISION ST
Practice Address - Street 2:SUITE 217
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4515
Practice Address - Country:US
Practice Address - Phone:320-253-4136
Practice Address - Fax:320-253-4179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN800356-1-MHC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN024755301Medicaid