Healthcare Provider Details

I. General information

NPI: 1760396576
Provider Name (Legal Business Name): SOUTHEAST BEHAVIORAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 9TH AVE S
FARGO ND
58103-2350
US

IV. Provider business mailing address

2624 9TH AVE S
FARGO ND
58103-2350
US

V. Phone/Fax

Practice location:
  • Phone: 701-298-4500
  • Fax: 701-298-4400
Mailing address:
  • Phone: 701-298-4500
  • Fax: 701-298-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: LUCY OLSON
Title or Position: CLAIMS AND CLIENT ACCOUNTS MANAGER
Credential:
Phone: 701-328-8580