Healthcare Provider Details

I. General information

NPI: 1700955366
Provider Name (Legal Business Name): GEROPSYCH HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SPRUCE GROVE LN NW
BEMIDJI MN
56601-7746
US

IV. Provider business mailing address

611 SPRUCE GROVE LN NW P.O. BOX 155
BEMIDJI MN
56601-7746
US

V. Phone/Fax

Practice location:
  • Phone: 218-209-1137
  • Fax: 218-333-0335
Mailing address:
  • Phone: 218-209-1137
  • Fax: 218-333-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR1077485
License Number StateMN

VIII. Authorized Official

Name: MS. SAUNDA M ST. MARTIN
Title or Position: OWNER
Credential: NP-CNS
Phone: 218-209-1137