Provider Demographics
NPI:1700968088
Name:LUTHERAN SOCIAL SERVICE OF MINNESOTA
Entity Type:Organization
Organization Name:LUTHERAN SOCIAL SERVICE OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERWALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1800-582-5260
Mailing Address - Street 1:39400 MOONLIGHT BAY TRL
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572-7546
Mailing Address - Country:US
Mailing Address - Phone:218-863-2741
Mailing Address - Fax:
Practice Address - Street 1:211 HOLMES ST W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3023
Practice Address - Country:US
Practice Address - Phone:218-847-0629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN136321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty