Provider Demographics
NPI:1245673482
Name:COMMUNITY OUTREACH COUNSELING PC
Entity type:Organization
Organization Name:COMMUNITY OUTREACH COUNSELING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA LMFT
Authorized Official - Phone:320-905-0795
Mailing Address - Street 1:1617 HIGHWAY 12 E
Mailing Address - Street 2:SUITE 230
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-5814
Mailing Address - Country:US
Mailing Address - Phone:320-905-0795
Mailing Address - Fax:320-205-0030
Practice Address - Street 1:1617 HIGHWAY 12 E
Practice Address - Street 2:SUITE 230
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5814
Practice Address - Country:US
Practice Address - Phone:320-905-0795
Practice Address - Fax:320-205-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1071251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN168211300Medicaid