Provider Demographics
NPI:1336772425
Name:NORTHERN MINNESOTA ADDICTION WELLNESS CENTER
Entity Type:Organization
Organization Name:NORTHERN MINNESOTA ADDICTION WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGOT
Authorized Official - Middle Name:ELISSA
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:952-250-6641
Mailing Address - Street 1:4851 STACY ANN DR NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601
Mailing Address - Country:US
Mailing Address - Phone:218-444-2333
Mailing Address - Fax:
Practice Address - Street 1:4851 STACY ANN DR NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-444-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility