Provider Demographics
NPI:1689111601
Name:FIVE RIVERS MENTAL HEALTH LLC
Entity type:Organization
Organization Name:FIVE RIVERS MENTAL HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIFERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:507-345-7012
Mailing Address - Street 1:1650 MADISON AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5471
Mailing Address - Country:US
Mailing Address - Phone:507-345-7012
Mailing Address - Fax:507-388-6937
Practice Address - Street 1:1650 MADISON AVE
Practice Address - Street 2:STE 102
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5471
Practice Address - Country:US
Practice Address - Phone:507-345-7012
Practice Address - Fax:507-388-6937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-28
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5185261QM0801X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1689111601Medicaid