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General NPI Number Information
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NPI Number | 1699958777
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Entity Type | Organization
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Legal Business Name | PRAIRIE LAKES YOUTH PROGRAMS
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Dates
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Enumeration Date | 12/11/2007
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Last Update Date | 12/11/2007
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Provider Practice Location Address
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Address Line | 1808 CIVIC CENTER DR
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City | WILLMAR
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State | MN
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Zip | 56201-9446
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Country | US
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Telephone | 320-231-1729
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Fax | 321-231-1166
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Provider Business Mailing Address
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Address Line | 1808 CIVIC CENTER DR PO BOX 894
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City | WILLMAR
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State | MN
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Zip | 56201-9446
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Country | US
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Telephone | 320-231-1729
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Fax | 321-231-1166
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DARIN BALKEN
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Credential |
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Telephone | 320-231-1729
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 1036941-1-CRF
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License Number State | MN
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