Provider Demographics
NPI:1336415942
Name:ST. SOPHIE'S, LLC
Entity Type:Organization
Organization Name:ST. SOPHIE'S, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMET
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:701-365-4488
Mailing Address - Street 1:3120Z 25TH ST S # 340
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5054
Mailing Address - Country:US
Mailing Address - Phone:701-365-4488
Mailing Address - Fax:701-365-4127
Practice Address - Street 1:5045 E COTTONTAIL RUN RD
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-3316
Practice Address - Country:US
Practice Address - Phone:701-365-4488
Practice Address - Fax:701-365-4127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7174261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health