Healthcare Provider Details

I. General information

NPI: 1124963947
Provider Name (Legal Business Name): HEALING CENTER COMMUNITY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 45TH ST S APT 202
FARGO ND
58103-0903
US

IV. Provider business mailing address

536 45TH ST S APT 202
FARGO ND
58103-0903
US

V. Phone/Fax

Practice location:
  • Phone: 701-540-1191
  • Fax:
Mailing address:
  • Phone: 701-540-1191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WR0400X
TaxonomyRehabilitation Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: KHALIYAH MARSHALL
Title or Position: OWNER
Credential:
Phone: 701-540-1191