Provider Demographics
NPI:1962549022
Name:UPPER SIOUX COMMUNITY
Entity type:Organization
Organization Name:UPPER SIOUX COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CD COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHAWK
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:320-564-6356
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56241-0147
Mailing Address - Country:US
Mailing Address - Phone:320-564-2360
Mailing Address - Fax:320-564-2550
Practice Address - Street 1:5744 HWY 67
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56241
Practice Address - Country:US
Practice Address - Phone:320-564-2360
Practice Address - Fax:320-564-2550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301298101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty