1619229754 NPI number — NORTHERN LIGHTS PSYCHOLOGICAL SERVICES P.A.

Table of content: (NPI 1619229754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619229754 NPI number — NORTHERN LIGHTS PSYCHOLOGICAL SERVICES P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN LIGHTS PSYCHOLOGICAL SERVICES P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619229754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNDERWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56586-0003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-828-1433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 FRONTIER DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FERGUS FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56537-1023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-828-1433
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
507-828-1433

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  LP4330 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6178609 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 589175200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 978T6PS . This is a "BCBS OF MN" identifier . This identifiers is of the category "OTHER".




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