Healthcare Provider Details

I. General information

NPI: 1053150995
Provider Name (Legal Business Name): STANDING TALL RECOVERY & CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3523 45TH ST S STE 105
FARGO ND
58104-8962
US

IV. Provider business mailing address

4902 16TH AVE S APT 101
FARGO ND
58103-8943
US

V. Phone/Fax

Practice location:
  • Phone: 701-799-6012
  • Fax:
Mailing address:
  • Phone: 701-799-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHENIKA BORDEAUX-COLLINS
Title or Position: DIRECTOR
Credential: LMAC
Phone: 701-799-6012