Basic Information
| Provider Information | |||||||||
| NPI: | 1104837251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEFSTAD | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Practice Location | |||||||||
| Address1: | 1726 S WASHINGTON ST STE 33A | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582016370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017464584 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 428-9-1-99 | ND | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 428-9-1-99 | ND | N | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | 428-9-1-99 | ND | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YP2500X | 428-9-1-99-237 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 450226423 | 01 | ND | FEDERAL TAX ID | OTHER |