Provider Demographics
NPI:1417140575
Name:NORTHLAND CHRISTIAN COUNSELING CENTER
Entity type:Organization
Organization Name:NORTHLAND CHRISTIAN COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:701-795-8550
Mailing Address - Street 1:1615 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5372
Mailing Address - Country:US
Mailing Address - Phone:701-795-8550
Mailing Address - Fax:
Practice Address - Street 1:211 ARNOLD AVE N
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-1827
Practice Address - Country:US
Practice Address - Phone:701-795-8550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71058Medicare PIN