Provider Demographics
NPI:1982085395
Name:FOUR RIVERS, LLC
Entity Type:Organization
Organization Name:FOUR RIVERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:VANDE WEERD
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT,LPC-MH,QMHP
Authorized Official - Phone:605-692-6444
Mailing Address - Street 1:922 4TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2173
Mailing Address - Country:US
Mailing Address - Phone:605-692-6444
Mailing Address - Fax:605-692-8997
Practice Address - Street 1:922 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2173
Practice Address - Country:US
Practice Address - Phone:605-692-6444
Practice Address - Fax:605-692-8997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575272Medicaid