Provider Demographics
NPI:1891713681
Name:PSYCHIATRIC RECOVERY PA
Entity Type:Organization
Organization Name:PSYCHIATRIC RECOVERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:CLUTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-294-3436
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 229N
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114
Mailing Address - Country:US
Mailing Address - Phone:651-645-3115
Mailing Address - Fax:651-645-2752
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 229N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:651-645-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1339261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03101Medicare ID - Type Unspecified