Provider Demographics
NPI:1457544686
Name:CENTRAL MINNESOTA COUSELING CENTER, INC.
Entity Type:Organization
Organization Name:CENTRAL MINNESOTA COUSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:O
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA LP
Authorized Official - Phone:320-253-4321
Mailing Address - Street 1:1500 NORTHWAY DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4477
Mailing Address - Country:US
Mailing Address - Phone:320-253-4321
Mailing Address - Fax:320-240-8525
Practice Address - Street 1:1500 NORTHWAY DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4477
Practice Address - Country:US
Practice Address - Phone:320-253-4321
Practice Address - Fax:320-240-8525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1710992243Medicaid
MN1033200233Medicaid
MN1699882217Medicaid
MN1770690380Medicaid