Provider Demographics
NPI:1992185524
Name:NORTHLAND RECOVERY CENTER
Entity Type:Organization
Organization Name:NORTHLAND RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PRACTITIONER, TRAINEE
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:VIZENOR
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:21832-711-0524
Mailing Address - Street 1:1215 SE 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4201
Mailing Address - Country:US
Mailing Address - Phone:218-327-1105
Mailing Address - Fax:
Practice Address - Street 1:1215 SE 7TH AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4201
Practice Address - Country:US
Practice Address - Phone:218-327-1105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YM0800X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health