Provider Demographics
NPI:1740452093
Name:STINSON, ROBERTA J (MAC, LMAC, LADC, LAT)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:STINSON
Suffix:
Gender:F
Credentials:MAC, LMAC, LADC, LAT
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:GRIFFIN-STINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4227 9TH AVE SW
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:701-282-6564
Mailing Address - Fax:701-277-0306
Practice Address - Street 1:4227 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2018
Practice Address - Country:US
Practice Address - Phone:701-282-6561
Practice Address - Fax:651-925-0046
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-359101YA0400X
MN302304101YA0400X
ND1517101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)