Healthcare Provider Details

I. General information

NPI: 1710268966
Provider Name (Legal Business Name): MICHAEL JOEL MELGAARD LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 3RD ST SE
MINOT ND
58701-4470
US

IV. Provider business mailing address

1805 2ND AVE SW APT 209
MINOT ND
58701-3499
US

V. Phone/Fax

Practice location:
  • Phone: 701-371-3558
  • Fax:
Mailing address:
  • Phone: 701-371-3558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1652
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: