Provider Demographics
NPI:1043860109
Name:ST. CLOUD NEUROBEHAVIORAL ASSOCIATES, PA
Entity type:Organization
Organization Name:ST. CLOUD NEUROBEHAVIORAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-253-3833
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-0230
Mailing Address - Country:US
Mailing Address - Phone:320-253-3833
Mailing Address - Fax:320-253-5741
Practice Address - Street 1:3812 8TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1421
Practice Address - Country:US
Practice Address - Phone:320-253-3833
Practice Address - Fax:320-253-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03196Medicaid