Basic Information
| Provider Information | |||||||||
| NPI: | 1649441304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDVIK | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9859 | ||||||||
| Address2: | 1201 25TH ST S | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581069859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014515056 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581069859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014515056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 02/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1571 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 11669 | MN | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 4633 | ND | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.