Healthcare Provider Details

I. General information

NPI: 1487824587
Provider Name (Legal Business Name): COUNTRY COUNSELING & CONSULTING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 12TH AVE NE
DEVILS LAKE ND
58301-2712
US

IV. Provider business mailing address

400 12TH AVE NE
DEVILS LAKE ND
58301-2712
US

V. Phone/Fax

Practice location:
  • Phone: 701-665-5433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number23613700
License Number StateND

VIII. Authorized Official

Name: MS. DEBORAH L HANSON
Title or Position: PRESIDENT
Credential: LICSW
Phone: 701-665-5433