Healthcare Provider Details

I. General information

NPI: 1386548071
Provider Name (Legal Business Name): KATELYN WILLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3788 55TH AVE S STE 218
FARGO ND
58104-5588
US

IV. Provider business mailing address

3788 55TH AVE S STE 218
FARGO ND
58104-5588
US

V. Phone/Fax

Practice location:
  • Phone: 701-353-5092
  • Fax:
Mailing address:
  • Phone: 701-353-5092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1596-10-1-26A
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: