Provider Demographics
NPI:1740576354
Name:ARK COUNSELING
Entity Type:Organization
Organization Name:ARK COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:MA MPH LPCC LADC
Authorized Official - Phone:763-559-5677
Mailing Address - Street 1:13895 INDUSTRIAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3700
Mailing Address - Country:US
Mailing Address - Phone:763-559-5677
Mailing Address - Fax:
Practice Address - Street 1:13895 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3723
Practice Address - Country:US
Practice Address - Phone:763-559-5677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302560101YA0400X
MN00416101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty