Healthcare Provider Details

I. General information

NPI: 1750701280
Provider Name (Legal Business Name): MARY J SOLBERG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 4TH AVE NW
MINOT ND
58703
US

IV. Provider business mailing address

1705 4TH AVE NW
MINOT ND
58703-2912
US

V. Phone/Fax

Practice location:
  • Phone: 701-839-0474
  • Fax: 701-839-0713
Mailing address:
  • Phone: 701-839-0474
  • Fax: 701-839-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2997
License Number StateND

VII. Legacy identifiers

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

# 1
IdentifierN717658
Identifier TypeOTHER
Identifier StateND
Identifier IssuerMEDICARE PTAN
# 2
Identifier19302
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 3
Identifier717658
Identifier TypeOTHER
Identifier StateND
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name: CHAR HICKEL
Title or Position: OFFICE MANAGER
Credential:
Phone: 701-839-0474