Healthcare Provider Details

I. General information

NPI: 1912243148
Provider Name (Legal Business Name): BEACON BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2012
Last Update Date: 12/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W BEATON DR SUITE 103
WEST FARGO ND
58078-2652
US

IV. Provider business mailing address

102 W BEATON DR SUITE 103
WEST FARGO ND
58078-2652
US

V. Phone/Fax

Practice location:
  • Phone: 701-356-1276
  • Fax: 701-356-4940
Mailing address:
  • Phone: 701-356-1276
  • Fax: 701-356-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number421
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number372
License Number StateND

VIII. Authorized Official

Name: KARLA BUSKIRK
Title or Position: OFFICE MANAGER
Credential:
Phone: 701-356-1276