Healthcare Provider Details

I. General information

NPI: 1164122693
Provider Name (Legal Business Name): ELIJAH NIKKALETTE PASCHKE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 DIVISION AVE
GRAND FORKS ND
58201-4702
US

IV. Provider business mailing address

340 DIVISION AVE
GRAND FORKS ND
58201-4702
US

V. Phone/Fax

Practice location:
  • Phone: 866-427-8370
  • Fax:
Mailing address:
  • Phone: 866-427-8370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6364
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: