Healthcare Provider Details

I. General information

NPI: 1407045461
Provider Name (Legal Business Name): NORTHLAND COUNSELING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 S POKEGAMA AVE
GRAND RAPIDS MN
55744-4210
US

IV. Provider business mailing address

215 SE 2ND AVE
GRAND RAPIDS MN
55744-3615
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-1151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: K. GREG WALKER
Title or Position: CEO
Credential:
Phone: 218-326-0099