Provider Demographics
NPI:1932146941
Name:SOUTHEAST HUMAN SERVICE CENTER
Entity Type:Organization
Organization Name:SOUTHEAST HUMAN SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:STENSETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-298-4500
Mailing Address - Street 1:2624 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2350
Mailing Address - Country:US
Mailing Address - Phone:701-298-4500
Mailing Address - Fax:701-298-4400
Practice Address - Street 1:2624 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2350
Practice Address - Country:US
Practice Address - Phone:701-298-4500
Practice Address - Fax:701-298-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QM0801X, 261QM0850X, 261QM0855X
ND1015261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054520Medicaid
MN90981SOOtherBCBS OF MN
ND100001OtherBCBS OF ND
NDN6336Medicare ID - Type UnspecifiedMEDICARE GROUP ID