Provider Demographics
NPI:1437662970
Name:DANIELSON, EBEN BLAKE
Entity Type:Individual
Prefix:
First Name:EBEN
Middle Name:BLAKE
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:701-451-4855
Mailing Address - Fax:651-925-0057
Practice Address - Street 1:815 37TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5524
Practice Address - Country:US
Practice Address - Phone:701-451-4811
Practice Address - Fax:651-925-0057
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01693101YP2500X
MN01905101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional