MEDICARE: RAY OF HOPE COUNSELONG SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1651	ND

General Provider Information

NPI Number	:	1609227180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAY OF HOPE COUNSELONG SERVICES

Provider Business Mailing Address
First Line	:	3140 BLUE STEM DR
Second Line	:	#405
City	:	WEST FARGO
State	:	ND
Zip	:	58078-8009
Country	:	US
Telephone Number	:	701-793-7692
Fax Number	:

Provider Business Practice Location Address
First Line	:	3140 BLUE STEM DR
Second Line	:	#405
City	:	WEST FARGO
State	:	ND
Zip	:	58078-8009
Country	:	US
Telephone Number	:	701-793-7692
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SUPERVISOE
Name	:	WANDA LYNN CROWE
Credential	:	LAC, LADC
Telephone Number	:	701-793-7692

Provider Enumeration Date	:	06/27/2016
Last Update Date	:	06/27/2016

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