Provider Demographics
NPI:1356576979
Name:SHAREHOUSE GENESIS
Entity type:Organization
Organization Name:SHAREHOUSE GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAEN
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW,LCAC,LADCMBA
Authorized Official - Phone:701-532-4345
Mailing Address - Street 1:4227 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2018
Mailing Address - Country:US
Mailing Address - Phone:701-282-6561
Mailing Address - Fax:651-925-0046
Practice Address - Street 1:505 40TH ST S UNIT B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1184
Practice Address - Country:US
Practice Address - Phone:701-478-8440
Practice Address - Fax:651-925-0046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAREHOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-27
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QR0405X
ND1056324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder