Healthcare Provider Details

I. General information

NPI: 1740862036
Provider Name (Legal Business Name): MATTHEW RASK LAPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4200
US

IV. Provider business mailing address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4200
US

V. Phone/Fax

Practice location:
  • Phone: 651-529-8315
  • Fax: 218-331-4867
Mailing address:
  • Phone: 218-331-4866
  • Fax: 218-331-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1114-3-15-21A
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3090
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: