Provider Demographics
NPI:1336443654
Name:ST. SOPHIE'S, LLC
Entity Type:Organization
Organization Name:ST. SOPHIE'S, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FREI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-365-4467
Mailing Address - Street 1:3201 33RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8823
Mailing Address - Country:US
Mailing Address - Phone:701-365-4488
Mailing Address - Fax:701-365-0727
Practice Address - Street 1:3201 33RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8823
Practice Address - Country:US
Practice Address - Phone:701-365-4488
Practice Address - Fax:701-365-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7174261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15685Medicaid
ND15685Medicaid