Healthcare Provider Details

I. General information

NPI: 1104058254
Provider Name (Legal Business Name): KEVIN ROSS JUNTUNEN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7785 SAINT GERTRUDE AVE
RALEIGH ND
58564-4103
US

IV. Provider business mailing address

614 9TH AVE NE
ROLLA ND
58367-7303
US

V. Phone/Fax

Practice location:
  • Phone: 701-597-3419
  • Fax:
Mailing address:
  • Phone: 701-278-1192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1607
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: