Healthcare Provider Details

I. General information

NPI: 1235412388
Provider Name (Legal Business Name): SHAREHOUSE MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 40TH ST S UNIT A
FARGO ND
58103-1184
US

IV. Provider business mailing address

4227 9TH AVE S
FARGO ND
58103-2018
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-8440
  • Fax:
Mailing address:
  • Phone: 701-282-6561
  • Fax: 651-925-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1056
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEREMY TRAEN
Title or Position: CEO/PRESIDENT
Credential: LBSW,LCAC,LADC.MBA
Phone: 701-532-4345