Healthcare Provider Details

I. General information

NPI: 1508664111
Provider Name (Legal Business Name): MINDWELL BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3285 FIECHTNER DR S
FARGO ND
58103-2488
US

IV. Provider business mailing address

3285 FIECHTNER DR S STE B
FARGO ND
58103-2490
US

V. Phone/Fax

Practice location:
  • Phone: 651-485-9373
  • Fax:
Mailing address:
  • Phone: 701-361-8273
  • Fax: 701-301-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
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: ALEX ROEDER
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 701-361-8273