Healthcare Provider Details

I. General information

NPI: 1326420936
Provider Name (Legal Business Name): KENNETH FLANAGAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 PAGE DR S STE 202
FARGO ND
58103-3536
US

IV. Provider business mailing address

1351 PAGE DR S STE 202
FARGO ND
58103-3536
US

V. Phone/Fax

Practice location:
  • Phone: 701-353-9979
  • Fax: 701-212-1700
Mailing address:
  • Phone: 701-353-9979
  • Fax: 701-212-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4497
License Number StateND

VII. Legacy identifiers

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

# 1
Identifier4497
Identifier TypeOTHER
Identifier StateND
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: