Healthcare Provider Details

I. General information

NPI: 1194262014
Provider Name (Legal Business Name): EXPERIENCE COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3523 45TH ST S
FARGO ND
58104-8962
US

IV. Provider business mailing address

3523 45TH ST S
FARGO ND
58104-8962
US

V. Phone/Fax

Practice location:
  • Phone: 701-639-6561
  • Fax:
Mailing address:
  • Phone: 701-639-6561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1633
License Number StateND

VII. Legacy identifiers

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

VIII. Authorized Official

Name: AMANDA RAE DECKER
Title or Position: CEO
Credential: LAC
Phone: 701-639-6561