Provider Demographics
NPI:1205904612
Name:PORT OF CROW WING COUNTY, INC
Entity type:Organization
Organization Name:PORT OF CROW WING COUNTY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-639-1425
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-0367
Mailing Address - Country:US
Mailing Address - Phone:320-632-6647
Mailing Address - Fax:320-639-0014
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:2006-12-01
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN059T5POOtherBLUECROSS BLUESHIELD
MN62-764-39OtherUNITED BEHAVORIAL HEALTH
MN131919OtherU CARE
MN82364OtherHEALTH PARTNERS
MN006031300Medicaid
MN34B87POOtherBLUECROSS BLUESHIELD