Healthcare Provider Details

I. General information

NPI: 1336443654
Provider Name (Legal Business Name): ST. SOPHIE'S, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2010
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 33RD ST S
FARGO ND
58104-8823
US

IV. Provider business mailing address

3201 33RD ST S
FARGO ND
58104-8823
US

V. Phone/Fax

Practice location:
  • Phone: 701-365-4488
  • Fax: 701-365-0727
Mailing address:
  • Phone: 701-365-4488
  • Fax: 701-365-0727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7174
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number7174
License Number StateND

VIII. Authorized Official

Name: TRACEY JEAN FREI
Title or Position: OFFICE MANAGER
Credential:
Phone: 701-365-4467