Healthcare Provider Details

I. General information

NPI: 1265376131
Provider Name (Legal Business Name): STEPHAN ROBERT NOLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 32ND ST S STE 1
FARGO ND
58103-6304
US

IV. Provider business mailing address

808 3RD AVE S STE 303
FARGO ND
58103-1865
US

V. Phone/Fax

Practice location:
  • Phone: 701-264-5200
  • Fax:
Mailing address:
  • Phone: 701-248-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1537-4-15-26A
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: