Healthcare Provider Details

I. General information

NPI: 1275484347
Provider Name (Legal Business Name): LINETTE WILSON LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2026
Last Update Date: 02/05/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2126 VISTA AVE
ARNEGARD ND
58854-7719
US

IV. Provider business mailing address

124 4TH AVE SE APT 1
WATFORD CITY ND
58854-7719
US

V. Phone/Fax

Practice location:
  • Phone: 701-586-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2409
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: