MEDICARE: INSIGHT FORENSIC PSYCHOLOGY LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1740683242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSIGHT FORENSIC PSYCHOLOGY LLC

Provider Business Mailing Address
First Line	:	12 S 3RD ST
Second Line	:	SUITE 203
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4798
Country	:	US
Telephone Number	:	701-730-2033
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 S 3RD ST
Second Line	:	SUITE 203
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4798
Country	:	US
Telephone Number	:	701-730-2033
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CHIEF EXECUTIVE OFFICER
Name	:	DR. TROY WILLIAM ERTELT
Credential	:	PH.D.
Telephone Number	:	701-730-2033

Provider Enumeration Date	:	09/29/2014
Last Update Date	:	09/29/2014

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