Basic Information
Provider Information
NPI: 1003146861
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLUMHARDT
FirstName: RACHEL
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1201 25TH ST S
Address2: PO BOX 9859
City: FARGO
State: ND
PostalCode: 581032311
CountryCode: US
TelephoneNumber: 7014514900
FaxNumber: 7014515056
Practice Location
Address1: 2701 12TH AVE S
Address2:  
City: FARGO
State: ND
PostalCode: 581038753
CountryCode: US
TelephoneNumber: 7014514900
FaxNumber: 6519250057
Other Information
ProviderEnumerationDate: 12/30/2009
LastUpdateDate: 02/17/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/17/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X522-2-1-05-198NDY Behavioral Health & Social Service ProvidersCounselorProfessional
101YP2500X522-2-1-05NDN Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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