Provider Demographics
NPI:1043271885
Name:CENTER FOR PSYCHIATRIC CARE
Entity type:Organization
Organization Name:CENTER FOR PSYCHIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-732-2500
Mailing Address - Street 1:1451 44TH AVE S, UNIT A
Mailing Address - Street 2:PO BOX 14545
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-732-2500
Mailing Address - Fax:701-732-2501
Practice Address - Street 1:1451 44TH AVE S
Practice Address - Street 2:UNIT A
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-732-2500
Practice Address - Fax:701-732-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND101YP2500X, 103T00000X, 1041C0700X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18009Medicaid
ND567001OtherND BC/BS
MN536318700OtherMN MEDICAID
ND70539Medicare ID - Type Unspecified