Provider Demographics
NPI:1841382108
Name:CORE PROFESSIONAL SERVICES, P.A.
Entity Type:Organization
Organization Name:CORE PROFESSIONAL SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-839-4785
Mailing Address - Street 1:617 OAK ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3610
Mailing Address - Country:US
Mailing Address - Phone:218-829-7140
Mailing Address - Fax:
Practice Address - Street 1:617 OAK ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3610
Practice Address - Country:US
Practice Address - Phone:218-829-7140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103T00000X
MN0103103TC0700X
MN2585103TC0700X
MN4659103TC0700X
MN1885103TC0700X
MN4630103TC0700X
MN1517103TC0700X
MN001311041C0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62G67COOtherBCBS
MN62G71COOtherBCBS
MN62G69COOtherBCBS
MN028078000Medicaid
MN028078000Medicaid