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General NPI Number Information
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NPI Number | 1265977284
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Entity Type | Organization
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Legal Business Name | NORTHSTAR BEHAVIORAL HEALTH CRANBERRY ACRES, LLC
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Dates
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Enumeration Date | 12/29/2016
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 5810 CRANBERRY DR
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City | WYOMING
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State | MN
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Zip | 55092-9499
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Country | US
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Telephone | 612-749-8751
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Fax |
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Provider Business Mailing Address
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Address Line | 5810 CRANBERRY DR
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City | WYOMING
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State | MN
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Zip | 55092-9499
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Country | US
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Telephone | 612-749-8751
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Fax |
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Authorized Official
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Title or Position | OWNER / EXECUTIVE DIRECTOR
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Name | MS. WENDY KAY STEWART
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Credential | MA, LADC
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Telephone | 612-749-8751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 1083755
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License Number State | MN
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