Healthcare Provider Details

I. General information

NPI: 1275194136
Provider Name (Legal Business Name): INTEGRATED INTERVENTION SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 02/01/2025
Certification Date: 02/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 31ST AVE S STE A
FARGO ND
58104-7743
US

IV. Provider business mailing address

4215 31ST AVE S STE A
FARGO ND
58104-7743
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-0221
  • Fax: 701-478-0222
Mailing address:
  • Phone: 701-478-0221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACLYN MARTINSON
Title or Position: OWNER
Credential:
Phone: 701-341-6025