Provider Demographics
NPI:1821422544
Name:CROWN IMPERIAL PRESS, LLC
Entity Type:Organization
Organization Name:CROWN IMPERIAL PRESS, LLC
Other - Org Name:STEVEN R. WIESE, M.S., M.DIV, LICENSED PSYCHOLOGIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MDIV, LP
Authorized Official - Phone:651-785-3920
Mailing Address - Street 1:21211 IMPERIAL AVE N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-9547
Mailing Address - Country:US
Mailing Address - Phone:651-785-3920
Mailing Address - Fax:
Practice Address - Street 1:1935 COUNTY ROAD B2 W
Practice Address - Street 2:SUITE #102
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-2729
Practice Address - Country:US
Practice Address - Phone:651-785-3920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1426261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)