Provider Demographics
NPI:1932540127
Name:MINNESOTA STATE UNIVERSITY MOORHEAD
Entity Type:Organization
Organization Name:MINNESOTA STATE UNIVERSITY MOORHEAD
Other - Org Name:COMMUNITY OUTREACH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ERIE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:218-477-2506
Mailing Address - Street 1:113 LOMMEN
Mailing Address - Street 2:1104 7TH AVE S
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56563-1013
Mailing Address - Country:US
Mailing Address - Phone:218-477-2506
Mailing Address - Fax:
Practice Address - Street 1:113 LOMMEN
Practice Address - Street 2:1104 7TH AVE S
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56563-1013
Practice Address - Country:US
Practice Address - Phone:218-477-2506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty