Healthcare Provider Details

I. General information

NPI: 1588998090
Provider Name (Legal Business Name): PRAIRIER ST JOHN'S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 4TH ST S
FARGO ND
58103-1914
US

IV. Provider business mailing address

510 4TH ST S
FARGO ND
58103-1914
US

V. Phone/Fax

Practice location:
  • Phone: 710-476-7863
  • Fax: 615-312-5711
Mailing address:
  • Phone: 710-476-7863
  • Fax: 615-312-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER HOWARD
Title or Position: CEO
Credential:
Phone: 701-476-7863