Healthcare Provider Details

I. General information

NPI: 1629492715
Provider Name (Legal Business Name): JOHN BUTGEREIT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 S BROADWAY SUITE 18
MINOT ND
58701-4667
US

IV. Provider business mailing address

1015 S BROADWAY SUITE 18
MINOT ND
58701-4667
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-8500
  • Fax: 701-857-8555
Mailing address:
  • Phone: 701-857-8500
  • Fax: 701-857-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number781-3-15-14-235
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: