Healthcare Provider Details

I. General information

NPI: 1699081539
Provider Name (Legal Business Name): NATHAN JOHN ELLENSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

151 S 4TH ST STE 401
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 TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1001-4-15-19
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: