Provider Demographics
NPI:1053483248
Name:CITY OF WHITE BEAR LAKE MN
Entity type:Organization
Organization Name:CITY OF WHITE BEAR LAKE MN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR ADMINISTRATIVE & CLINICAL
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:BELLE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LICSW LP LMFT LI
Authorized Official - Phone:651-429-8544
Mailing Address - Street 1:1280 NORTH BIRCH LAKE BLVD
Mailing Address - Street 2:WHITE BEAR LAKE AREA COMMUNITY COUNSELING CENTER
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-6708
Mailing Address - Country:US
Mailing Address - Phone:651-429-8544
Mailing Address - Fax:651-407-5301
Practice Address - Street 1:1280 NORTH BIRCH LAKE BLVD
Practice Address - Street 2:WHITE BEAR LAKE AREA COMMUNITY COUNSELING CENTER
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-6708
Practice Address - Country:US
Practice Address - Phone:651-429-8544
Practice Address - Fax:651-407-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8026811MHC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
N008855OtherCHAMPUS CLINIC #
MN29626WHOtherBLUE CROSS BLUE SHIELD
MN102981OtherUCARE MINNESOTA CLINIC #
C01709Medicare ID - Type Unspecified