Provider Demographics
NPI:1013904051
Name:NORTHERN PINES MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:NORTHERN PINES MENTAL HEALTH CENTER, INC.
Other - Org Name:NORTHERN PINES MENTAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:JD
Authorized Official - Phone:320-632-6647
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:1906 5TH AVE SE
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-0367
Mailing Address - Country:US
Mailing Address - Phone:320-632-6642
Mailing Address - Fax:320-632-9525
Practice Address - Street 1:1906 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3317
Practice Address - Country:US
Practice Address - Phone:320-632-6647
Practice Address - Fax:320-632-9525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8017541MHC261QM0801X
MN1001061CDT261QR0405X
MN10102841CDT261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN83367N0OtherBCBS OF MINNESOTA
MN834755700Medicaid
MN4788N0OtherBCBS OF MINNESOTA
MN98224OtherPREFERRED ONE
MN007444000Medicaid
MN126039OtherUCARE MINNESOTA
MN195354100Medicaid
MN6369OtherHEALTH PARTNERS
MN83367N0OtherBCBS OF MINNESOTA
MNC02425Medicare ID - Type Unspecified