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General NPI Number Information
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NPI Number | 1932922085
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Entity Type | Organization
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Legal Business Name | FOUNDATIONS MENTAL HEALTH CLINIC, PC
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Dates
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Enumeration Date | 11/06/2024
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 4040 42ND ST S STE N
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City | FARGO
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State | ND
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Zip | 58104-4352
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Country | US
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Telephone | 701-388-5825
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Fax |
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Provider Business Mailing Address
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Address Line | 4040 42ND ST S STE N
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City | FARGO
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State | ND
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Zip | 58104-4352
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN WIEDMANN
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Credential | PA-C
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Telephone | 701-543-5533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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