Healthcare Provider Details

I. General information

NPI: 1568492353
Provider Name (Legal Business Name): VILLAGE FAMILY SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 12TH AVE S
FARGO ND
58103-8753
US

IV. Provider business mailing address

2701 12TH AVE S
FARGO ND
58103-8753
US

V. Phone/Fax

Practice location:
  • Phone: 701-451-4900
  • Fax: 651-925-0057
Mailing address:
  • Phone: 701-451-4900
  • Fax: 651-925-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number316-8-1-95-97
License Number StateND

VIII. Authorized Official

Name: AMBROSIA BURKE
Title or Position: INSURANCE SPECIALIST
Credential:
Phone: 701-451-4865