Provider Demographics
NPI:1295121648
Name:DOCTORS PARK MENTAL HEALTH CENTER, PA
Entity type:Organization
Organization Name:DOCTORS PARK MENTAL HEALTH CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:COULTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:320-316-0300
Mailing Address - Street 1:103 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1207
Mailing Address - Country:US
Mailing Address - Phone:320-316-0300
Mailing Address - Fax:
Practice Address - Street 1:103 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1207
Practice Address - Country:US
Practice Address - Phone:320-316-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1503106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty