Healthcare Provider Details

I. General information

NPI: 1679694616
Provider Name (Legal Business Name): CENTRAL MINNESOTA MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 12TH AVE S
BUFFALO MN
55313-2321
US

IV. Provider business mailing address

1321 13TH ST N
SAINT CLOUD MN
56303-2613
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-4400
  • Fax: 763-682-1353
Mailing address:
  • Phone: 320-252-5010
  • Fax: 320-203-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number807286-5-CDT
License Number StateMN

VIII. Authorized Official

Name: DAVID BARAGA
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D, LP
Phone: 320-252-5010