Healthcare Provider Details

I. General information

NPI: 1033298104
Provider Name (Legal Business Name): TRACY E MOHN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 4TH ST S
FARGO ND
58103-1929
US

IV. Provider business mailing address

3310 28TH AVE S
FARGO ND
58103-7829
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3106
  • Fax: 701-234-3106
Mailing address:
  • Phone: 701-234-3106
  • Fax: 701-234-3106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3124
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: