Basic Information
| Provider Information | |||||||||
| NPI: | 1639130917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAKOTA FAMILY SERVICES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DAKOTA FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1148 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587021148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018580115 | ||||||||
| FaxNumber: | 7018521190 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 22ND AVE NW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587030986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018376508 | ||||||||
| FaxNumber: | 7018581839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 07/20/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GANTZER | ||||||||
| AuthorizedOfficialFirstName: | SHONDELL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7018580115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 06641001 | 01 | ND | BLUE CROSS BLUE SHIELD ND | OTHER | 13527 | 05 | ND | MEDICAID |