Healthcare Provider Details

I. General information

NPI: 1740744853
Provider Name (Legal Business Name): EVE-LYNN R FELLERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W SUPERIOR ST STE 200
DULUTH MN
55802-3000
US

IV. Provider business mailing address

104 W SUPERIOR ST STE 200
DULUTH MN
55802-3000
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-7353
  • Fax: 218-727-2646
Mailing address:
  • Phone: 218-727-7353
  • Fax: 218-727-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: