Basic Information
Provider Information | |||||||||
NPI: | 1275194136 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRATED INTERVENTION SPECIALISTS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4891 38TH AVE S | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581048516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017992045 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4725 AMBER VALLEY PKWY S STE B | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581048614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7014780221 | ||||||||
FaxNumber: | 7014780222 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2019 | ||||||||
LastUpdateDate: | 11/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAMAN | ||||||||
AuthorizedOfficialFirstName: | RACHEL | ||||||||
AuthorizedOfficialMiddleName: | ERIN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7017992045 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1538310792 | 05 | ND |   | MEDICAID |