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General NPI Number Information
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NPI Number | 1225357437
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Entity Type | Organization
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Legal Business Name | PEAR LAKE WOMEN'S FACILITY - OUTPATIENT
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Dates
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Enumeration Date | 05/27/2010
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Last Update Date | 03/30/2021
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Provider Practice Location Address
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Address Line | 2086 RIDGEWAY DR
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City | GRAND RAPIDS
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State | MN
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Zip | 55744-4421
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Country | US
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Telephone | 218-327-9944
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Fax | 218-327-9944
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Provider Business Mailing Address
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Address Line | 2086 RIDGEWAY DR
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City | GRAND RAPIDS
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State | MN
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Zip | 55744-4421
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Country | US
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Telephone | 218-327-9944
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Fax | 218-327-9944
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Authorized Official
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Title or Position | SUPERVISOR
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Name | ARIKA STANLEY
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Credential |
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Telephone | 218-327-9944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 10026213CDT
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License Number State | MN
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