Healthcare Provider Details

I. General information

NPI: 1932540127
Provider Name (Legal Business Name): MINNESOTA STATE UNIVERSITY MOORHEAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LOMMEN 1104 7TH AVE S
MOORHEAD MN
56563-1013
US

IV. Provider business mailing address

113 LOMMEN 1104 7TH AVE S
MOORHEAD MN
56563-1013
US

V. Phone/Fax

Practice location:
  • Phone: 218-477-2506
  • Fax:
Mailing address:
  • Phone: 218-477-2506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN LEE ERIE
Title or Position: CLINIC COORDINATOR
Credential: LPC
Phone: 218-477-2506