Basic Information
| Provider Information | |||||||||
| NPI: | 1215323332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OVERBO | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | B | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2624 9TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012984500 | ||||||||
| FaxNumber: | 7012984400 | ||||||||
| Practice Location | |||||||||
| Address1: | 2624 9TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012984500 | ||||||||
| FaxNumber: | 7012984400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2015 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.