Provider Demographics
NPI:1588110530
Name:NORTHLAND RECOVERY PINEVIEW CENTER
Entity type:Organization
Organization Name:NORTHLAND RECOVERY PINEVIEW CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:218-283-3406
Mailing Address - Street 1:900 5TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:912 MAIN ST UNIT B
Practice Address - Street 2:
Practice Address - City:LITTLEFORK
Practice Address - State:MN
Practice Address - Zip Code:56653-9379
Practice Address - Country:US
Practice Address - Phone:218-278-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHLAND COUNSELING CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301742324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility