Healthcare Provider Details

I. General information

NPI: 1619763299
Provider Name (Legal Business Name): IMPACT THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3426 BAY SHORE BND SE
MANDAN ND
58554-6259
US

IV. Provider business mailing address

3426 BAY SHORE BND SE
MANDAN ND
58554-6259
US

V. Phone/Fax

Practice location:
  • Phone: 701-516-6980
  • Fax:
Mailing address:
  • Phone: 701-516-6980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: HEATHER MOSER
Title or Position: OWNER
Credential: LMAC, LAPC
Phone: 701-516-6980