Provider Demographics
NPI:1750701280
Name:MARY J SOLBERG
Entity type:Organization
Organization Name:MARY J SOLBERG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-839-0474
Mailing Address - Street 1:1705 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2912
Mailing Address - Country:US
Mailing Address - Phone:701-839-0474
Mailing Address - Fax:701-839-0713
Practice Address - Street 1:1705 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703
Practice Address - Country:US
Practice Address - Phone:701-839-0474
Practice Address - Fax:701-839-0713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND29971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN717658OtherMEDICARE PTAN
ND19302Medicaid
ND717658OtherMEDICARE PTAN