Healthcare Provider Details

I. General information

NPI: 1174164537
Provider Name (Legal Business Name): KEIRAN VITEK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 37TH AVE S
MOORHEAD MN
56560
US

IV. Provider business mailing address

1201 25TH ST S
FARGO ND
58103-2311
US

V. Phone/Fax

Practice location:
  • Phone: 701-451-4811
  • Fax: 651-925-0057
Mailing address:
  • Phone: 701-451-4900
  • Fax: 651-925-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25653
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: