Individual
ROD OPP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LAC, LSW.
Contact information
Practice address
4227 9TH AVE S, FARGO, ND 58103-2018
(701) 282-6561
(651) 925-0046
Mailing address
4227 9TH AVE S, FARGO, ND 58103-2018
(701) 282-6561
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
1750
ND
Other
Enumeration date
05/01/2015
Last updated
05/01/2015
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