Healthcare Provider Details

I. General information

NPI: 1992185524
Provider Name (Legal Business Name): NORTHLAND RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 SE 7TH AVE
GRAND RAPIDS MN
55744-4201
US

IV. Provider business mailing address

1215 SE 7TH AVE
GRAND RAPIDS MN
55744-4201
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-1105
  • Fax:
Mailing address:
  • Phone: 218-327-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number101YM0800X
License Number StateMN

VIII. Authorized Official

Name: LAURIE BETH VIZENOR
Title or Position: MENTAL HEALTH PRACTITIONER, TRAINEE
Credential: M.S.
Phone: 218327110524