Healthcare Provider Details

I. General information

NPI: 1093389736
Provider Name (Legal Business Name): CLEARWATERS CROSBY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14091 BAXTER DR STE 112
BAXTER MN
56425-8703
US

IV. Provider business mailing address

15157 LADYSLIPPER LN
DEERWOOD MN
56444-8918
US

V. Phone/Fax

Practice location:
  • Phone: 218-585-2052
  • Fax:
Mailing address:
  • Phone: 218-585-2058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TANYA KUBISTA
Title or Position: OWNER
Credential: LMFT
Phone: 218-585-2052