Provider Demographics
NPI:1912242819
Name:CROSSROADS CHRISTIAN CENTER
Entity Type:Organization
Organization Name:CROSSROADS CHRISTIAN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARRIAGE/ FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:KULLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-747-7224
Mailing Address - Street 1:4165 SHORELINE DR
Mailing Address - Street 2:SUITE 15
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-9659
Mailing Address - Country:US
Mailing Address - Phone:612-747-7224
Mailing Address - Fax:
Practice Address - Street 1:4165 SHORELINE DR
Practice Address - Street 2:SUITE 15
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384-9659
Practice Address - Country:US
Practice Address - Phone:612-747-7224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1886251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health