Basic Information
| Provider Information | |||||||||
| NPI: | 1902940182 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAKOTA FAMILY SERVICES, INC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | DAKOTA FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1148 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587021148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018376508 | ||||||||
| FaxNumber: | 7018581839 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 45TH ST SW | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018376508 | ||||||||
| FaxNumber: | 7018581839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | IREY | ||||||||
| AuthorizedOfficialFirstName: | CONNIE | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7018376508 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 13661 | 05 | ND | MEDICAID | 06641001 | 01 | ND | BLUE CROSS BLUE SHIELD ND | OTHER | 06641002 | 01 | ND | BCBS OF ND | OTHER |