Provider Demographics
NPI:1720266794
Name:NORTHLAND COUNSELING CENTER KOOCH OFFICE
Entity Type:Organization
Organization Name:NORTHLAND COUNSELING CENTER KOOCH OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-327-1151
Mailing Address - Street 1:215 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1404 HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2154
Practice Address - Country:US
Practice Address - Phone:218-327-1151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC0 8155Medicare PIN