Provider Demographics
NPI:1912713157
Name:GRANITE CITY ACT
Entity type:Organization
Organization Name:GRANITE CITY ACT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:320-420-1356
Mailing Address - Street 1:6645 COUNTY ROAD 4 NE
Mailing Address - Street 2:
Mailing Address - City:KANDIYOHI
Mailing Address - State:MN
Mailing Address - Zip Code:56251-9752
Mailing Address - Country:US
Mailing Address - Phone:320-420-1356
Mailing Address - Fax:
Practice Address - Street 1:1017 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2413
Practice Address - Country:US
Practice Address - Phone:320-420-1356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-03
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty