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General NPI Number Information
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NPI Number | 1932540127
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Entity Type | Organization
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Legal Business Name | MINNESOTA STATE UNIVERSITY MOORHEAD
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Dates
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Enumeration Date | 07/16/2013
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Last Update Date | 07/16/2013
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Provider Practice Location Address
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Address Line | 113 LOMMEN 1104 7TH AVE S
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City | MOORHEAD
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State | MN
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Zip | 56563-1013
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Country | US
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Telephone | 218-477-2506
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Fax |
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Provider Business Mailing Address
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Address Line | 113 LOMMEN 1104 7TH AVE S
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City | MOORHEAD
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State | MN
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Zip | 56563-1013
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Country | US
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Telephone | 218-477-2506
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Fax |
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Authorized Official
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Title or Position | CLINIC COORDINATOR
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Name | BENJAMIN LEE ERIE
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Credential | LPC
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Telephone | 218-477-2506
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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