Provider Demographics
NPI:1225414956
Name:30:17 COUNSELING
Entity Type:Organization
Organization Name:30:17 COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL CLINICAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:701-541-0313
Mailing Address - Street 1:1751 MAIN AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2203
Mailing Address - Country:US
Mailing Address - Phone:701-541-0313
Mailing Address - Fax:
Practice Address - Street 1:1751 MAIN AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-2203
Practice Address - Country:US
Practice Address - Phone:701-541-0313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND666-9-1-10-243261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)