| NPI | 1346761442 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CARMEN JACKSON Credentialing Specialist 701-298-4690 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2017-06-29 |
| Last Update Date | 2025-10-23 |