Healthcare Provider Details

I. General information

NPI: 1013904051
Provider Name (Legal Business Name): NORTHERN PINES MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 5TH AVE SE
LITTLE FALLS MN
56345-3317
US

IV. Provider business mailing address

PO BOX 367 1906 5TH AVE SE
LITTLE FALLS MN
56345-0367
US

V. Phone/Fax

Practice location:
  • Phone: 320-632-6647
  • Fax: 320-632-9525
Mailing address:
  • Phone: 320-632-6642
  • Fax: 320-632-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number8017541MHC
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1001061CDT
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number10102841CDT
License Number StateMN

VIII. Authorized Official

Name: LAURA VAUGHN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 320-639-2025