Provider Demographics
NPI:1699958777
Name:PRAIRIE LAKES YOUTH PROGRAMS
Entity type:Organization
Organization Name:PRAIRIE LAKES YOUTH PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-231-1729
Mailing Address - Street 1:1808 CIVIC CENTER DR
Mailing Address - Street 2:PO BOX 894
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-9446
Mailing Address - Country:US
Mailing Address - Phone:320-231-1729
Mailing Address - Fax:321-231-1166
Practice Address - Street 1:1808 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-9446
Practice Address - Country:US
Practice Address - Phone:320-231-1729
Practice Address - Fax:321-231-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1036941-1-CRF101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty