Provider Demographics
NPI:1831177195
Name:CENTRAL MINNESOTA MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:CENTRAL MINNESOTA MENTAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:320-252-5010
Mailing Address - Street 1:1321 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2613
Mailing Address - Country:US
Mailing Address - Phone:320-252-5010
Mailing Address - Fax:320-203-1855
Practice Address - Street 1:1321 13TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2613
Practice Address - Country:US
Practice Address - Phone:320-252-5010
Practice Address - Fax:320-203-1855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN804852-1-DS101YA0400X
MN800832-2-CDT101YA0400X
MN807286-3-CDT101YA0400X
MN809836-2-CDT101YA0400X
MN1022869-1-CDT101YA0400X
MN800357-1-CDT101YA0400X
MN809140-1-RMI320800000X
MN800356-1-MHC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN664725100Medicaid
MN233650200Medicaid
MN492319700Medicaid
MN024755301Medicaid
MN127824000Medicaid
MN742698400Medicaid
MN676555600Medicaid
MN764442600Medicaid
MN024755300Medicaid
MN492319700Medicaid
MN024755301Medicaid