MEDICARE: RED LAKE DEPARTMENT OF FAMILY AND CHILDREN SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	0001324	MN

General Provider Information

NPI Number	:	1376753160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RED LAKE DEPARTMENT OF FAMILY AND CHILDREN SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 427
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0427
Country	:	US
Telephone Number	:	218-679-2122
Fax Number	:	218-679-2929

Provider Business Practice Location Address
First Line	:	13586 TRIBAL AGENCY STREET
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0427
Country	:	US
Telephone Number	:	218-679-2122
Fax Number	:	218-679-2929

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. SANDRA PARSONS
Credential	:	PHD
Telephone Number	:	218-679-2122

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	10/15/2007

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Directions to “RED LAKE DEPARTMENT OF FAMILY AND CHILDREN SERVICES ” Practice Location

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