Provider Demographics
NPI:1962659532
Name:HIAWATHA VALLEY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:HIAWATHA VALLEY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-454-4341
Mailing Address - Street 1:420 E SARNIA ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-6365
Mailing Address - Country:US
Mailing Address - Phone:507-454-4341
Mailing Address - Fax:
Practice Address - Street 1:611 BROADWAY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WABASHA
Practice Address - State:MN
Practice Address - Zip Code:55981-1988
Practice Address - Country:US
Practice Address - Phone:651-565-2234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN708556700Medicaid