Provider Demographics
NPI:1689778912
Name:CHILDRENS HEALTH CARE
Entity Type:Organization
Organization Name:CHILDRENS HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP AND CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA LU
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-813-6129
Mailing Address - Street 1:5901 LINCOLN DRIVE, CBC-2-REV/PE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-1611
Mailing Address - Country:US
Mailing Address - Phone:952-992-5691
Mailing Address - Fax:952-992-6917
Practice Address - Street 1:2525 CHICAGO AVE S
Practice Address - Street 2:CHILDRENS SPECIALITY CLINIC PSYCHOLOGICAL SERVICES MPLS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-813-8455
Practice Address - Fax:612-813-8263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331018261QM0801X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN435247500Medicaid
C02022Medicare ID - Type Unspecified