Healthcare Provider Details

I. General information

NPI: 1356558878
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF ND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 20TH AVE S
FARGO ND
58103
US

IV. Provider business mailing address

PO BOX 389
FARGO ND
58107-0389
US

V. Phone/Fax

Practice location:
  • Phone: 701-235-7341
  • Fax:
Mailing address:
  • Phone: 701-235-7341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier050955
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier55350
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 3
Identifier57446
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 4
Identifier54635
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 5
Identifier0005817398
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 6
Identifier10355
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBLUE CROSS BLUE SHIELD ND
# 7
Identifier50-50094
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICA

VIII. Authorized Official

Name: MS. JESSICA THOMMASON
Title or Position: PRESIDENT CEO
Credential:
Phone: 701-235-7341