Provider Demographics
NPI:1053596577
Name:NORTHEAST COUNSELING, P.A.
Entity type:Organization
Organization Name:NORTHEAST COUNSELING, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:G
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-398-6341
Mailing Address - Street 1:2127 COUNTY ROAD D E STE A100
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5350
Mailing Address - Country:US
Mailing Address - Phone:651-592-1592
Mailing Address - Fax:651-429-2988
Practice Address - Street 1:2127 COUNTY ROAD D E STE A100
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5350
Practice Address - Country:US
Practice Address - Phone:651-592-1592
Practice Address - Fax:651-429-2988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1053596577Medicaid