Provider Demographics
NPI:1710227103
Name:PARK AVENUE CENTER
Entity Type:Organization
Organization Name:PARK AVENUE CENTER
Other - Org Name:PARK AVENUE CENTER MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CASAGRANDE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:612-871-7443
Mailing Address - Street 1:2649 PARK AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1006
Mailing Address - Country:US
Mailing Address - Phone:612-871-7443
Mailing Address - Fax:612-871-0194
Practice Address - Street 1:2649 PARK AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1006
Practice Address - Country:US
Practice Address - Phone:612-871-7443
Practice Address - Fax:612-871-0194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK AVENUE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty