MEDICARE: DHARMA RAJ PANTHA LAC, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1638	ND
2	101YM0800X	Mental Health Counselor	678-1-1-11	ND

General Provider Information

NPI Number	:	1285930735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DHARMA RAJ PANTHA LAC, LPC

Provider Business Mailing Address
First Line	:	231 KEMP AVE SE
Second Line	:	APT # 112
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-3978
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 WALNUT ST E
Second Line	:	SUIT # 7
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-3411
Country	:	US
Telephone Number	:	701-665-2149
Fax Number	:	701-665-2153

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2011
Last Update Date	:	02/01/2011

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