MEDICARE: CENTRAL MINNESOTA MENTAL HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	801767-1-RMI	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225016306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL MINNESOTA MENTAL HEALTH CENTER

Provider Business Mailing Address
First Line	:	1321 13TH ST N
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-2613
Country	:	US
Telephone Number	:	320-252-5010
Fax Number	:	320-203-1855

Provider Business Practice Location Address
First Line	:	1509 24TH AVE N
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1306
Country	:	US
Telephone Number	:	320-252-8648
Fax Number	:	320-529-4909

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. DAVID J. BARAGA
Credential	:	PH.D., LP
Telephone Number	:	320-252-5010

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	08/05/2009

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