Healthcare Provider Details

I. General information

NPI: 1467279117
Provider Name (Legal Business Name): ELIZABETH CLAIRE RADLE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH CLAIRE RADLE LAC

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 S 4TH ST STE 401
GRAND FORKS ND
58201-4715
US

IV. Provider business mailing address

151 S 4TH ST
GRAND FORKS ND
58201-4715
US

V. Phone/Fax

Practice location:
  • Phone: 701-795-3000
  • Fax: 701-795-3050
Mailing address:
  • Phone: 701-795-3000
  • Fax: 701-795-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1984
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: