Healthcare Provider Details

I. General information

NPI: 1871942953
Provider Name (Legal Business Name): PROVIDENCE PSYCHIATRY SERVICES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 SE 10TH ST
GRAND RAPIDS MN
55744-3921
US

IV. Provider business mailing address

12860 MUD LAKE RD NE BOX 631
DEER RIVER MN
56636-2174
US

V. Phone/Fax

Practice location:
  • Phone: 218-246-6286
  • Fax:
Mailing address:
  • Phone: 218-398-1998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberCNP2221
License Number StateMN

VIII. Authorized Official

Name: MS. JEAN M VANEPS
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: APRN
Phone: 218-398-1998