=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932265048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAKOTA THERAPY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2007
-----------------------------------------------------
Last Update Date | 07/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 DEMERS AVE STE 301
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201-4599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-746-9341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 DEMERS AVE STE 301
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201-4599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JENNIFER ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-746-9341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 995
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 266
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------