Provider Demographics
NPI:1851496368
Name:HOPE HOUSE OF ITASCA COUNTY, INC.
Entity Type:Organization
Organization Name:HOPE HOUSE OF ITASCA COUNTY, INC.
Other - Org Name:PEAR LAKE WOMEN'S FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MARCHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-327-9944
Mailing Address - Street 1:2086 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4421
Mailing Address - Country:US
Mailing Address - Phone:218-327-9944
Mailing Address - Fax:218-327-9375
Practice Address - Street 1:2086 RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4421
Practice Address - Country:US
Practice Address - Phone:218-327-9944
Practice Address - Fax:218-327-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
MN1002621-2324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN642634400Medicaid