Basic Information
| Provider Information | |||||||||
| NPI: | 1235358037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STERN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9859 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581069859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Practice Location | |||||||||
| Address1: | 4133 IOWA ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207628851 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7483 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103T00000X | 1449 | MN | N | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 56308-A004 | 01 | MN | TRI WEST | OTHER | 522853100 | 05 | MN | MEDICAID | 62-70233 | 01 | MN | MEDICA UBH | OTHER | 31002005 | 01 | MN | PRIMEWEST | OTHER | 06H9ST | 01 | MN | BCBS MN | OTHER |