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	101YA0400X	Addiction (Substance Use Disorder) Counselor	800832-2-CDT	MN
2	324500000X	Substance Abuse Rehabilitation Facility	800832-2-CDT	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	676555600	OTHER	MN	PROVIDER NUMBER

General Provider Information

NPI Number	:	1386766426
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	:	3220 8TH STREET NORTH
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-3128
Country	:	US
Telephone Number	:	320-252-2425
Fax Number	:	320-529-1976

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DAVID BARAGA
Credential	:	PH.D, LP
Telephone Number	:	320-202-2033

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	12/20/2010

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