Healthcare Provider Details

I. General information

NPI: 1053627984
Provider Name (Legal Business Name): NORTHERN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S JAY ST
ABERDEEN SD
57401-7155
US

IV. Provider business mailing address

1200 S JAY ST
ABERDEEN SD
57401-7155
US

V. Phone/Fax

Practice location:
  • Phone: 605-626-2566
  • Fax:
Mailing address:
  • Phone: 605-626-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. DON ERLENBUSCH
Title or Position: V.P OF FINANCE & ADMINISTRATION
Credential:
Phone: 605-626-2566