Healthcare Provider Details

I. General information

NPI: 1679554497
Provider Name (Legal Business Name): CEDAR RIVER COUNSELING & EDUCATIONAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 15TH AVE NW
AUSTIN MN
55912-1911
US

IV. Provider business mailing address

1403 15TH AVE NW
AUSTIN MN
55912-1911
US

V. Phone/Fax

Practice location:
  • Phone: 507-433-6482
  • Fax: 507-433-0097
Mailing address:
  • Phone: 507-433-6482
  • Fax: 507-433-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3235
License Number StateMN

VIII. Authorized Official

Name: DR. STANLEY R MILLER
Title or Position: DIRECTOR/PSYCHOLOGIST
Credential: PSY.D.,L.P.
Phone: 507-433-6482