Healthcare Provider Details

I. General information

NPI: 1003367103
Provider Name (Legal Business Name): MEDICINE HORSE COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10435 63RD AVE NE
ROCKLAKE ND
58365-9517
US

IV. Provider business mailing address

10435 63RD AVE NE
ROCKLAKE ND
58365-9517
US

V. Phone/Fax

Practice location:
  • Phone: 701-266-5118
  • Fax:
Mailing address:
  • Phone: 701-266-5118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1605
License Number StateND

VIII. Authorized Official

Name: WANDA JEAN LAMOTTE-PETERSON
Title or Position: OWNER/DIRECTOR
Credential: LAC
Phone: 701-266-5118